Inspection on 18/07/07 for Old Vicarage, (The)

This inspection was carried out on 18th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Old Vicarage, (The) 03/06/08

Old Vicarage, (The) 07/04/06

Old Vicarage, (The) 19/12/05

Old Vicarage, (The) 26/10/04

Old Vicarage, (The) 17/05/04

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

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

CARE HOMES FOR OLDER PEOPLE Old Vicarage, (The) Yeld Road Bakewell Derbyshire DE45 1FJ Lead Inspector Angela Kennedy Unannounced Inspection 18th July 2007 11:00 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 Old Vicarage, (The) DS0000052437.V341250.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, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Vicarage, (The) Address Yeld Road Bakewell Derbyshire DE45 1FJ 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) 01629 814659 01629 814330 Info@Westwickgroup.com The Westwick Group of Businesses Limited Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th April 2006 Brief Description of the Service: The Old Vicarage is a well-established residential care home in the town of Bakewell. There is access to local facilities including shops, parks, library, cafes and public houses. The home is registered to admit up to 25 older people with personal care needs. The home is set within well-maintained gardens and there is outside seating provision for the service users. Service user accommodation comprises of 23 single rooms and 1 double room, which are accessed by shaft lift of staircase. Nineteen of the bedrooms are equipped with en suite facilities. There are a variety of communal areas, including a conservatory at the rear of the building. Car parking space is provided at the front of the home. At the time of inspection the weekly fee Items not covered by this fee included: Hairdresser Chiropody Newspapers/Magazines Optical treatment (this does not include eye test) at The Old Vicarage was £505 to £520. £5 per visit £10 per visit Varies dependent on items purchased. Varies dependent on treatment and products purchased. Further information regarding the home and the current scale of charges can be obtained by contacting the home directly by telephone or email. The providers website also has information about the home along with photographs and the most recently published inspection report. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately five 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 residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment and the information provided within this assessment has also been used within this inspection report. Eight Care home surveys completed by residents and their representatives have also been used to inform this report. The acting manager was present at the inspection and the regional manager, who oversees the quality assurance systems within the Westwick Group of residential homes, was also present. The provider was also present for part of the inspection visit. Staff opinions were also sought to ascertain their views of the service and their opinion of the training and support provided to them. The commission had received a complaint regarding two residents and the action taken by staff following a fall. The information provided was addressed against the National Minimum Standards at this inspection and the outcomes of these findings are included within this report. Two residents 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, talking to the resident if they are able to communicate or observing the care they receive. Several other residents were also spoken with at this inspection visit and two visitors. What the service does well: The Old Vicarage is a well maintained home, which provides a comfortable, homely environment for the people that live there. All of the residents and visitors spoken with on the day of the inspection were very complimentary regarding the care and support provided. Comments Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 6 included “ staff are absolutely lovely, incredibly patient, they are fabulous. Very caring and loving” and “ staff are very good” and “ am very happy with level of care provided to mum”. Observation of staff with residents appeared relaxed, friendly and respectful. What has improved since the last inspection? What they could do better: All complaints must be recorded, including verbal complaints this is to ensure that an audit trail is in place regarding all complaints received, the actions taken and the outcome of complaints. The home must ensure that all moving and handling procedures are undertaken using the correct moving and handling equipment and procedures and evidence of this recorded within care plans and accident / incident records. A protocol/procedure regarding the actions to be taken following a fall or accident would better inform staff of the procedures to follow and provide continuity of care. Safe working practices must be in place for any resident who has been assessed as at risk if leaving the building without staff support or supervision. Old Vicarage, (The) DS0000052437.V341250.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. Old Vicarage, (The) DS0000052437.V341250.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, (The) DS0000052437.V341250.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Before a decision regarding admission to The Old Vicarage is made, a thorough assessment of needs prior to admission is undertaken. This determines that the services and care provided will meet individuals assessed needs. EVIDENCE: There were twenty-one people living at The Old Vicarage on the day of the inspection. Written information provided by the home prior to this inspection stated that all prospective residents are assessed before entering home and offered a trial period. Written assessments are in place to demonstrate this. This is also included in Statement Of Purpose and Service User Guide. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 10 The pre admission assessments of the two residents case tracked was looked at. This was to establish if sufficient information regarding each persons needs had been sought prior to admission. To enable a decision to be made as to the suitability of the home for each person. Both of these residents had lived at The Old Vicarage for a considerable length of time and therefore the assessments in place that had been undertaken prior to admission did not provide a thorough assessment of need. Therefore the pre admission assessment of a resident who had moved into the home within the last six months was looked at. This assessment was thorough and covered all areas of health, personal and social care. This demonstrates that no resident moves into the home without having their needs assessed and being assured that they will be met by the service. Old Vicarage, (The) DS0000052437.V341250.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 adequate. This judgement has been made using available evidence including a visit to this service. Generally resident’s needs and strengths were assessed, maintained and promoted, this however requires further development to ensure a robust practice is in place and maintained. EVIDENCE: Written information provided by the home prior to this inspection stated improvements had been made in care plans and all residents care plans are now complete. It was stated in this information that key workers needed to be fully implemented. In the last twelve months it was stated that staff training regarding medication for all night staff had been undertaken. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 12 The plans for further improvement within the next twelve months included promoting person centred care through the key worker scheme and by reviewing care on a regular basis to promote continuity of care for the residents. Vast improvements were noted within the care plans in place within the two residents files seen. The first file seen had care plans that addressed all areas of need. These care plans provided detailed instruction for the staff team as to the level of support this individual needed in all areas of care. Risk assessments were in place that addressed the moving and handling practices in place for this individual and it was noted that these assessments were no longer valid at the present time due to the changing needs of this resident. This was discussed with the acting manager who confirmed these assessments would be reviewed. Assessments and records were in place that addressed nutritional needs and requirements, pressure areas and weight monitoring. All of the records seen were up to date. The second resident’s file looked at also had care plans that addressed nearly all areas of assessed needs. One of the risk assessments in place indicated that due to this resident’s confusion, aggressive behaviour may be displayed. However there was no care plan in place to address how this resident was to be supported and how this behaviour was to be managed Another risk assessments in place confirmed that this resident required assistance/ supervision from a carer when walking as mobility had deteriorated. However this resident had fallen in the grounds of the home and was found by staff. A complaint was made to the commission regarding the action that was taken. The accident was recorded, although the detail and the wording used was discussed at some length with the acting manager, regional manager and provider. From the records held it was not clear what moving and handling equipment was used to assist this person and there was no instruction to staff of the moving and handling procedure to use for this person, following a fall. Discussions took place with the acting manager, regional manager and provider regarding the protocol that was followed when a resident had an accident or fall. This included the decision to call a doctor or the emergency services. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 13 Information seen regarding a fall did not clearly demonstrate that a proactive approach to injuries/accidents/falls was maintained. This was discussed at some length with the acting manager, regional manager and provider. Evidence was in place to demonstrate residents had access to health care professionals and this included records that were maintained of doctor’s visits, hospital appointments and visits and appointments with other health care professionals. The medication practices at The Old Vicarage were looked and in general were good. Medication Administration records had been completed accurately and each resident was identified by a recent photograph. Staff received medication training through an accredited training company and all night staff had now undertaken this training. This ensured that any resident requiring medication in the evening or throughout the night was able to do so. Although a clinical fridge was in use for the storage of medication that required cold storage and a thermometer was in place to record the temperature within the fridge, temperatures were not being recorded. The acting manager stated that she had intended to implement this within the near future. Risk assessments were not in place for residents who self-administered their medication. Discussions took place with the acting manager regarding assessing the capacity of individuals who wish to retain and administer their own medicines. This is to ensure safe practices are maintained for the individual self-administering their medication and other residents. All of the residents and visitors spoken with on the day of the inspection were very complimentary regarding the care and support provided. Comments included “ staff are absolutely lovely, incredibly patient, they are fabulous. Very caring and loving” and “ staff are very good” and “ am very happy with level of care provided to mum”. Observation of staff with residents appeared relaxed, friendly and respectful. Old Vicarage, (The) DS0000052437.V341250.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. Residents maintain links with family and friends and efforts were made regarding activities and entertainment for residents. However these should be monitored to ensure they match resident’s expectations and satisfies their recreational interests and needs. EVIDENCE: Written information provided by the home prior to this inspection was as follows: Staff have formed excellent relationships with residents and relatives are always welcomed at any time. Generally the atmosphere at the home is always happy. The residents preferences are always listened to regarding meal choices. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 15 It was stated that the home could organise more activities and outings within the home.and that residents meetings had taken place and discussions about outings and activities have been organised and planning was in place. The homes plans for improvements within the next 12 months included: The key worker system which wouldl promote better relationships. Meal planning that was in place and decided by the residents themselves. Social evenings which had already taken place and were ongoing throughout the year. The drawing room is to be refurbished this summer, which will be complimented by a home cinema, as residents discussed at resident meetings a request to watch old movies. Summer outings which have been coordinated with residents, more musical afternoons and flower arranging. The main aim was to recruit an activities co-ordinator and also a part time administrator to help with planning and continuity for the residents. Several residents were spoken with on the day of the inspection and the general opinion was that more activities were required both within and outside of the home. One resident said that she was unable to get out alone but would love to have regular trips into Bakewell saying “ it would be lovely to pop into Bakewell for a look around, I spend most of my time just sat here”. This resident felt that when activities were offered they were not always appropriate saying “ sometimes they are a bit childish, I don’t want to join in with things like that”. One of the relatives who was spoken to at some length was generally full of praise for the home and the support provided by the staff team but said the one area that she felt could be improved upon was activities. Discussions took place with the acting manager who confirmed the plans to refurbish the drawing room as stated above. It was also confirmed that activities and trips out had been arranged for July and August. This included weekly trips out to places of interest such as Chatsworth House and daily activities within the home, such as music singalongs, hairdresser/nails/facials/hand and foot massage, slide shows, artability,progressive movement aerobics and reminicence sessions. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 16 Visiting at The Old Vicarage was open and discussions with one relative confirmed the positive relationship in place between herself and the staff team. This relative confirmed that due to the health care needs of her mum she had spent a lot of time at the Old Vicarage and found the acting manager and staff team to extremely helpful and considerate towards both herself and her mum. Residents spoken with were in general happy with the meal choices provided and comments were made such as “ the meals are excellent” and “ it’s all freshly cooked and you get good sized portions”. One resident although in agreement with the good quality of the meals said they thought the service was a bit slow. This resident stated that they would often have to wait some considerable time at the dining table both before their meal and after the meal when waiting for staff support to leave the table. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 17 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): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and appear confident that the home responds to their complaints promptly and effectively, however practices need to be further developed to demonstrate this. EVIDENCE: Written information provided by the home prior to this inspection stated all complaints are taken seriously and dealt with promptly and the home had received no written complaints only verbal ones that had been resolved quickly. The home felt they could do things better by providing a suggestion box in the home for residents, staff and visitors to provide suggestions for improvements. It was stated that in the last twelve months communication had improved between the residents and staff, which had resulted in higher standards of care being achieved. The plans for improvements within the next twelve months included continuing with residents meetings, ongoing staff training, promoting advocacy through the key worker system, relatives and family members. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 18 To continue advocating residents right to participate in the political process, enabling them to vote if they so wished. All of the residents spoken with were confident that any concerns or complaints they had would be dealt with promptly. Visitors spoken with were also confident that any concerns they had were always addressed promptly. One relative spoken with stated this saying “ if I ever have any concerns the staff always sought them out straight away, they’re very good”. The acting manager confirmed that three verbal complaints had been received by the home within the last twelve months. However these verbal complaints or their outcomes had not been recorded. This was discussed with the acting manager, as for purposes of audit and record keeping all complaints should be recorded including the action taken and their outcome. The commission had received a complaint regarding two residents and the action taken by staff following a fall. The information provided was addressed against the National Minimum Standards at this inspection and the outcomes of these findings are within this report. Evidence was in place within the two residents files seen to demonstrate that they were supported and able to participate in the political process through postal voting. Written information provided by the home prior to this inspection stated improvements within the next twelve months included, ongoing training for staff, ensuring the whistle blowing policy is fully adhered to and other policies relating to the suspicion or evidence of abuse, and that allegations or incidents are followed up promptly and the actions taken are recorded. The policies and procedures in place were in line with the local authority procedure on safeguarding adults. The regional manager had been trained by the local authority to provide staff training in safeguarding adults. Half of the staff team were up to date with this training and the other half of the staff team were booked onto training in August 2007, this included all staff such as domestic and catering staff as well as care staff. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 19 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): 19,22,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents at the home live in comfortable surroundings which are kept in good order and maintained to a high level of cleanliness and hygiene. Suitable adaptations and equipment would ensure residents health and safety are maintained. EVIDENCE: Written information provided by the home prior to this inspection stated that the home is very clean and welcoming and is kept in good order with resident’s safety as paramount. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 20 The information provided stated that a full time maintenance person was employed and two domestic staff. An ongoing refurbishment plan was in place to replace tired and worn areas of the home. The improvement plans for the next twelve months included a complete refurbishment of the drawing room. This included new carpets, curtains and furniture being upholstered and a cinema surround sound television. It was stated within this information that satellite television was also being purchased as advocated by the residents at the last residents meeting. It was stated that more lockable bedroom cabinets were to be purchased as residents move into the home and cabinets were also being replaced for the people already living at The Old Vicarage. It was stated that policies and procedures such as infection control were in place and that 90 of the staff team had undertaken infection control training and that this training was also covered at induction. A tour of the building was undertaken and all areas seen were clean.tidy and accessible to residents. The home was attractive in appearance and well maintained with a garden area and grounds that are visually pleasing and accessible to residents. Comments from residents regarding the standards of cleanliness maintained were very positive and included “ my room is beautiful and its very homely, they always keep it clean and tidy” and “ the cleaning staff and maintenance manager are very good”. The laundry area was seen and housed suitable equipment to maintain disinfection standards. Discussions took place with the acting manager, regional manager and provider regarding equipment that was used for moving and handling purposes when residents required lifting, such as if a resident fell. It was confirmed that a mobile hoist was available, although from discussions it appeared that this hoist was not used. The acting manager and regional manager discussed the suitability of manouvering this hoist around the building. Although it was confirmed that no resident is physically lifted by staff there was no evidence in the records seen to confirm this. As stated in standards 7-11 the records held regarding the fall of a resident did not state what moving and handling equipment was used to assist this person Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 21 and there was no instruction to staff of the moving and handling procedure to use for this person, following a fall. Standards 7-11 also looked at a risk assessment for a resident’s who required assistance/ supervision from a carer when walking as their mobility had deteriorated. However this resident had fallen in the grounds of the home and was found by staff. Discussions took place regarding how the safety of this resident and any other residents who were unable to go out alone could be maintained. This included the use of a wander mats or some alarm system that would alert staff if the front door was opened. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 22 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 Residents are supported by the training practices in place, which ensures their needs are met by the numbers and skill mix of staff. Further development is required to ensure residents are protected by the homes recruitment practices. EVIDENCE: Written information provided by the home prior to this inspection stated the staff are trained and competent to do their job, and the home adheres to strict policies and procedures regarding criminal records bureau checks, references and the recruitment process. Plans were in place within the next twelve months to promote further staff training to assist residents and their well being and the staff knowledge base. This training included dementia, stroke and diabetes. It was stated that ongoing training included NVQ 2 and 3, infection control, safeguarding adults, moving and handling and safe administration of medicines. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 23 Further improvements included promoting regular staff meetings, which are open, and that staff feel able to contribute to. The staffing levels in place at The Old Vicarage were 1 senior and 3 care staff in the morning, 1 senior and 2 care staff in the afternoon/ evening and 1 night staff and 1 sleep in at night. From the information provided prior to this inspection the numbers and dependency levels of the resident group were assessed against the residential forum staff tool. The staffing levels in place were within the recommended levels for the number of residents on the day of the inspection. However should the number of residents rise to full capacity and assuming the dependency levels remained the same, the numbers of staff per shift recommended by the residential forum staff tool is four staff on duty throughout the day and two waking night staff. Comments from residents and relatives indicated that staff worked hard and were “attentive and caring” but some comments from residents and their representatives indicated that there wasn’t sufficient numbers of staff on duty. Comments made included “ very good staff, but not enough of them especially at weekends” and “ sometimes it takes a while to get to speak to staff” and “care assistants are often rushed due to staff shortages” Discussions with the acting manager confirmed that staff levels had been reduced but it was confirmed that these posts were being advertised and on the day of inspection some interviews were taking place. Out of sixteen care staff five were trained at NVQ level 2 or above in care and five staff were working towards this qualification, therefore this home does not yet meet the national target of 50 of care staff being trained at NVQ 2 or above in care. The recruitment files of two members of staff were seen and in general they contained all of the required recruitment documentation. It was however noted that one member of staff only had one reference in place. The acting manager stated that this member of staff had previously worked at the home and then left for a short period before returning. Discussions took place with the regional manager regarding this and it was agreed that an additional reference would be requested. Staff training was up to date and this included all mandatory training. Recently undertaken training and training planned in the near future included dementia Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 24 care, moving and handling, fire training, health and safety and care of substances hazardous to health (COSHH) training. Staff spoken with confirmed that the training provided was very good and felt that it was sufficient in providing them with the knowledge required to meet resident’s needs. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 25 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. The health, safety and welfare of the residents is protected and promoted and evidence was in place to demonstrate that the home is run in the best interests of the residents. EVIDENCE: Written information provided by the home prior to this inspection stated that the acting manager had been in post for fourteen months, which had brought about positive changes to the home. This included a more open culture with residents and their families feeling that they are listened to and their wishes acted upon. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 26 Improvements for the next twelve months included continuing to audit and monitor the service provided to ensure that areas for improvement are strengthened. It was stated in the information provided, that the ideas for activities already discussed at residents meetings was to be implemented, and residents and relatives meetings were to be organised on a regular basis, to assist with feedback and create more involvement with residents and staff. The acting manager also stated that they would achieve the registered managers award by the end of 2007. At the time of this inspection the acting manager had not applied for registration with the commission. This was discussed with the regional manager. One member of staff spoken with stated that there had been a marked improvement in the management of the home and said that the manager provided an ‘open door’ policy for residents and staff. A residents meeting was held in January 2007 and the acting manager confirmed that the next residents meeting was booked for August 2007. Some of the residents and relatives spoken with confirmed this and were positive regarding residents meetings and the opportunities these meetings gave for them to discuss any ideas or preferences they had. As stated earlier in this report the requests from the last residents meeting had led to the total refurbishment planned for the drawing room which included a cinema surround television with satellite channels. This therefore demonstrates that the views of residents are acted upon to ensure they influence the running of their home. The system for handling residents’ personal monies (not fees) was examined and there was confirmation that there are suitable accounting procedures in place. The service/maintenance documentation indicated that residents are protected by robust procedures, with all evidence of gas and electrical services having been suitably checked/maintained. Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14 (2) Requirement Risk assessments must be reviewed regularly to ensure that any changing needs are recorded. Care plans must be formulated for all areas of risk identified. A proactive approach to healthcare must be maintained following a fall or any accident, and this must be recorded. Residents who choose to selfadminister and retain their medication must have a written assessment in place that demonstrates their capacity to do so. Clinical fridge temperatures must be recorded to ensure medicines requiring cold storage are stored at the correct temperature in line with the manufactures instructions. All complaints, including verbal complaints must be recorded, including the action taken and outcome of the complaint. Suitable moving and handling equipment must be in place to ensure residents safety can be DS0000052437.V341250.R01.S.doc Timescale for action 01/11/07 2 3 OP7 OP8 15 12 (1) (b) 01/11/07 30/09/07 4 OP9 13 (2) 30/09/07 5. OP9 13 (2) 30/09/07 6. OP16 22 01/11/07 7 OP22 23 (2) (n) 30/09/07 Old Vicarage, (The) Version 5.2 Page 29 8 OP22 13 (4) (c) 9. OP29 19 (1) (b) maintained at all times. Safe working practices must be in place for any resident who has been assessed as at risk if leaving the building without staff support or supervision. All records as specified in paragraphs 1 to 9 of schedule 2 must be in place prior to staff employment 30/09/07 30/09/07 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 OP12 Good Practice Recommendations Residents should be consulted about their social interests and arrangements made to enable them to engage in local, social and community activities A lockable facility should be provided in resident’s private accommodation unless the reason for not doing so is explained in the care plan 2. OP24 Old Vicarage, (The) DS0000052437.V341250.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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