Inspection on 24/09/08 for Old Vicarage, The

This inspection was carried out on 24th September 2008.

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

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

Other inspections for this house

Old Vicarage, The 23/09/09

Old Vicarage, The 03/09/07

Old Vicarage, The 25/07/06

Old Vicarage, The 04/01/06

Old Vicarage, The 04/05/05

Old Vicarage, The 11/01/05

Old Vicarage, The 02/07/04

Similar services:

22 Sandown Road

The Highlands

Turret Villa Retirement Home

Dilston College Of Further Education

West View House

Moor House

Prince Bishop Court

Park View (15)

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Old Vicarage, The 2 Waterville Road North Shields Tyne & Wear NE29 6SL Lead Inspector Elaine Malloy Key Unannounced Inspection 09:30 24 September, 9 & 24th October 2008 th th 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 DS0000000374.V372627.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 DS0000000374.V372627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Vicarage, The Address 2 Waterville Road North Shields Tyne & Wear NE29 6SL 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) 0191 2570937 sdewan@tiscali.co.uk Dr Sandeep Dewan Manager post vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (6), Learning registration, with number disability (2), Old age, not falling within any of places other category (17) Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two learning disability beds are currently occupied by named residents. If any of these residents vacate the beds CSCI must be notified and action will be taken to revert those places to the category of OP. 3rd September 2007 Date of last inspection Brief Description of the Service: The Old Vicarage is a privately owned care home that is situated in a residential area of North Shields, close to the town centre. The home provides personal care for up to 25 older people of both sexes. The accommodation is provided over two floors. The original building was extended and en-suite facilities are provided in the new part of the home only. Residents living in the home include people who require care due to old age and physical frailty, people with memory loss including dementia type illnesses, and some with physical disabilities. Weekly fees range from £379 to £394. A guide to the home’s services and inspection reports are available at the home. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was carried out by: • Looking at information received since the last inspection on 19th September 2007. • Getting the provider’s view of the service and how well they care for people. • An inspector visiting the home on 24th September and 9th October 2008. • Talking to the owner, management and staff about the service. • Looking at records about the people who use the service and how well their needs are met. • Looking at a range of other records that must be kept. • Checking that staff have the knowledge, skills and training to meet the needs of the people they support. • Getting the views of people who use the service, their relatives, and staff by talking to them and from surveys they completed. • Checking if improvements required from the last inspection have been made, including further information submitted by the manager, received on 24th October 2008. • The inspection was completed over 13 hours. What the service does well: The majority of residents and relatives were complimentary about the service. They said, “Overall we are satisfied with the care my mother receives”, “Quite happy and content”, and, “Never had any problems as the staff are really supportive”. The staff team and medical professionals support people to meet their health care needs. There are appropriate medication procedures and more staff are being trained to administer medication. There is a clear procedure for making complaints that residents and relatives understand. Procedures are in place to prevent abuse and staff will be getting further training on protecting vulnerable people. Staffing levels are appropriate to meet the needs of the number of people living at the home. The majority of care staff have gained nationally recognised care qualifications. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 7 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 DS0000000374.V372627.R01.S.doc Version 5.2 Page 8 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 and 3. Standard 6 is not applicable, as the home does not provide intermediate care. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Prospective residents have improved information to help them make informed choices and people’s needs are appropriately assessed before moving into the home. EVIDENCE: Seven residents who completed surveys said they received enough information before being admitted so they could decide if it was the right place for them. Three residents said they did not. The manager has now revised the documents that provide information on the home’s services and aims and objectives, as required at the last inspection. She will make sure that a copy of the home’s guide to services is given to new and existing residents. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 9 A sample of new resident care records was examined. These showed that people have an assessment of their physical and mental health needs before being admitted to the home. The requirement made at the last inspection, for all residents to have a copy of their pre-admission assessment on file, has been followed up. An assessment from the person’s social worker is also obtained. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 10 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 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Care planning does not consistently demonstrate that people’s health and personal care needs are fully met and a lack of medication training has potentially put people at risk of harm. EVIDENCE: Since the last inspection new care documentation has been introduced. A range of assessments is completed with associated care plans. These included plans for personal care, mobility, nutrition, mental health/behaviour, sensory, spiritual and communication needs. The sample of resident care plans examined was recorded to a variable standard. Some plans were adequately detailed and demonstrated how staff would meet the person’s needs. However other care plans had insufficient detail, interventions were not personalised and they did not include what residents are able to do independently. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 11 Care plans are now being evaluated on at least a monthly basis, as previously required. Each resident has a member of staff who is allocated as their ‘key worker’ and takes responsibility for keeping their care records up to date. The majority of residents who completed surveys said they always receive the care and support they need. One person said, “Quite happy and content” and another said, “Always get any help I need, I just ask”. Residents who spoke with the inspector indicated they are well looked after. One person described remaining independent and said they get the support they need. Relatives/friends who completed surveys said the home ‘usually’ or ‘sometimes’ meets the needs of their family member/friend, and ‘always’ or ‘usually’ gives the support/care they expected. Comments included, “Is well cared for”, and, “Never had any problems as the staff are really supportive”. Residents use four local GP practices. District Nurses currently visit the home 3-4 times weekly. Mental health professionals are accessed as needed on a referral basis. A Psychogeriatrician is involved with one resident and staff keep records to monitor behaviour. The home has arrangements for a chiropodist, dentist and optician to visit. All contact with health professionals is recorded in care records. Each person’s medical history is recorded. Physical and mental health needs, and risks associated with supporting individuals are assessed. Examples were seen of care plans to address diabetes, continence, and dietary needs. These were basic and lacked necessary detail. For example a continence plan stated only to ‘encourage use of commode during the night’ and gave no indication of the assistance to be given during the day. Two people’s care plans did not indicate that they have prescribed supplements to aid nutrition. More detailed plans for physical health needs are to be developed. Physical assessments and weights are now being kept up to date, as previously required. Residents who completed surveys and spoke to the inspector said they always receive the medical support they need. One person said, “If doctor required always available”. The home uses a monitored dosage system for prescribed medication. Medication is ordered on a monthly basis. There is a designated locked storage room. A new drugs fridge has been ordered. No residents are currently prescribed controlled drugs. An assessment of risks is carried out for any resident who wishes to continue to take responsibility for administering their own medication. The manager, deputy and senior staff only administers prescribed medication to residents. However, upon checking staff training it was evident that not all senior staff have undertaken medication training. The inspector advised that seniors should not be giving out medication until they have completed the Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 12 relevant training. The manager has since confirmed that training has been booked for these staff. A sample of medication administration records was examined. A photograph of each resident is needed on the records for identification purposes. The supplying pharmacist provides pre-printed charts with directions for medication. Staff record clear hand written directions. Charts were appropriately signed and codes are used to identify any reason why medication is not given. The home has policies and procedures on ensuring people’s privacy and dignity, and maintaining confidentiality. Some staff have had training on equality and diversity issues to give them understanding of the different needs individuals may have. Residents and relatives are asked about privacy and dignity at individual’s six monthly care review meetings. Personal care and medical examination/treatment is carried out in private. No bedrooms are currently shared and residents are offered keys to their rooms. Residents who spoke with the inspector said staff respect their privacy and dignity. Residents are asked how they wish to be addressed and this is recorded. The home provides an all female care team. Three residents have their own telephone. A pay telephone is available in the reception area, or residents can use one of the portable office telephones to make/receive calls in private. Post is given directly to residents and staff will provide support in reading/dealing with correspondence, if this is needed. Systems are in place to make sure residents wear their own clothing. Each person has an individual laundry basket, clothing is marked with initials and the home has dedicated laundry staff. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 13 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 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s social needs are not consistently met due to infrequent provision of activities and outings to maintain contact with the local community. EVIDENCE: At the last inspection the home was required to provide more opportunities for social activities to ensure residents have adequate stimulation and variety. The current weekly activities plan was said to be flexible and used as a guide. It includes dominoes/cards, arts and crafts, board games, bingo, carpet bowls, armchair exercises and films. There is no central record of activities that have taken place. Evaluations of social care plans showed infrequent activity participation. There was no evidence of any outings having taken place this year, or being organised. Funding resources for activities, outings and entertainment was discussed with the owner of the home and management to make sure that providing events and outings does not just rely on staff fundraising efforts to meet the costs. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 14 Residents said there are ‘usually’ or ‘sometimes’ activities arranged by the home that they can take part in. One relative said, “I think they could do a lot more activity wise for the residents as they never get out unless a relative comes”. Another relative said the home could improve by having more activities for residents. The manager was advised to introduce a forward planned programme of more varied activities. Following the inspection a monthly plan of activities was drawn up. The manager has agreed to allocate staff responsibility each day for providing activities and keeping records up to date, and to monitor provision. Newsletters are also being introduced for resident and relative information and these will include details of forthcoming events. The home has an open visiting policy and visitors are welcomed at any time. Visits can take place in resident bedrooms or in communal areas. Visitors can also stay for a meal if this is requested in advance. The home has links with a local church for seasonal events. One resident goes out to church. Management agreed to look into whether residents would like to have visits/services from local clergy. As previously stated there was no evidence of residents going on outings arranged by the home. The deputy manager said some residents have been out into the local area, accompanied by staff. New residents are encouraged to bring personal possessions into the home to make their bedrooms more homely. A ‘getting to know you’ document is completed on admission that indicates the person’s preferred routines; times of rising/retiring, meals, and that the person has been offered a key to their bedroom. People are given choice to follow their preferred routines, for example frequency and times of bathing. More choice of meals is being incorporated into the menus. Residents can continue to manage their personal finances, or be assisted by relatives or their own solicitor. The manager does not act as Appointee for any resident’s financial affairs. Cash for personal spending can be held in the home’s safe. Family and friends support residents and advocate on their behalf if needed. Relatives are invited to individual care reviews so they can be kept informed of any changes to the resident’s planned care. Relatives who completed surveys said they ‘always’, ‘usually’ or ‘sometimes’ get enough information about the service to help them make decisions. One person said, “Staff always make a point of keeping us informed”. Most said they are ‘always’ kept up to date with important issues affecting their family member/friend. One relative said, “Staff always inform one of the family”. The Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 15 deputy manager said staff try to involve residents in the assessment and care planning process and they can access their personal records if they wish. A new four-week cycle of menus has recently started, with improved choice and variety of meals. Breakfast consists of cereals, porridge, toast, fruit juice and cooked breakfast is available daily. There is a choice of main meal at lunch and lighter meal at tea, followed by dessert. Snack suppers are provided, for example sandwiches, cheese and crackers, crisps, yoghurts. Drinks and snacks are served between meals. Homemade milkshakes and fruit ‘smoothies’ are being introduced. Independent eating is encouraged. Staff provide support in cutting up food, and encouraging or prompting residents to eat their meals. Residents have their nutritional needs assessed and weights are monitored. Diabetic diets are provided. The cook said he completed training on special diets last year. Following discussion with the home’s owner and management it was agreed that fresh milk would be provided daily. Lunch on the day of the first visit was a choice of liver and onions with potato and vegetables or chicken pie, chips and peas, followed by rice pudding. Hot and cold drinks were served with the meal. Preference sheets were completed to show residents have been asked which meals they want. Residents spoken with confirmed they are offered choice of meals and said they enjoy the food. Most residents who completed surveys said they ‘always’ or ‘usually’ like the meals. Comments included, “I can get something else if I don’t like what’s on the menu”, and, “Always more than one choice provided”. Old Vicarage, The DS0000000374.V372627.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 and 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. While complaints are dealt with effectively and people are reasonably protected from harm, a lack of training about abuse may mean that staff do not recognise when to raise an alert. EVIDENCE: The complaints policy is displayed and included in the guide to the home’s services. All residents and relatives who completed surveys and spoke with the inspector said they would know how to make a complaint. Complaints records were examined. Two complaints were recorded, both of which concerned residents wanting to have their bedrooms redecorated. These were dealt with promptly and the manager said the residents had chosen the colour scheme. The home has policies and procedures on recognising and preventing abuse, and ‘whistle blowing’ (informing on bad practice). The deputy manager agreed to add the Commission for Social Care Inspection to the contact list of people to be notified in the event of an allegation of abuse. No allegations have made in the period since the last inspection. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 17 Whilst talking with staff and checking training records it was evident that not all staff had been provided with training on protecting vulnerable adults. The manager has since confirmed that this training is being organised. Old Vicarage, The DS0000000374.V372627.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, 20, 21, 25 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Decoration, facilities and infection control in the building are not to a good standard and do not provide people with a well-maintained and hygienic environment to live in. EVIDENCE: At the last inspection a number of requirements were made to improve the building. Some matters have been followed up, such as providing blinds and storage for toiletries in en suite bathrooms, and replacing the handrail on the ramp to the front entrance. The following issues were brought to the attention of the owner and manager after the inspector had toured the building. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 19 There is only one bathroom and one shower room in use. The bath and hoist are incompatible and this has resulted in the hoist causing a hole in the bath. The hole had been repaired with silicone but this is worn and water can still get through. This means that residents either cannot have enough water in the bath to be immersed whilst bathing, or if more water is used this will run through the hole and could cause problems with damp. There is no sluice in the home and commode pots are being cleaned in bathroom sinks. This is unacceptable and poses risk of infection. The owner said two small rooms/cupboards; one on each floor of the home had previously been used. However these have no sluicing or hand washing facilities present. A sluice needs to be created, ideally on the ground floor, as this is where there are bedrooms with commodes. The upper floor bedrooms have en suite toilets. Heating in one bedroom had been out of order for a number of days and a portable heater was being used. It was established that the valve on the radiator here is broken and needs to be replaced. Doors must not be chocked open and door guards need to be provided where residents choose to spend most of their time in their rooms and wish the door to be held open. A check should be made in all bedrooms in use to ensure residents can reach the pull cord to summon help from their beds. Unused rooms should be kept locked. The designated smoking room needs new ventilation as this is broken and has not been replaced. The ramp to the front door remains uneven and needs to be resurfaced. The majority of resident bedrooms were nicely personalised. Communal lounge and dining areas were generally comfortable. Improvements to the building are being made mainly on a reactive basis as problems occur, or when inspectors require issues be addressed. For example, two residents’ bedrooms were only redecorated after complaints were made. Another resident was moved to a different bedroom due to damp on the ceiling. A weekly record showed some general maintenance and repairs being carried out. The record also showed bedrooms needing redecoration but there was no evidence of these being done, and the entries were repeated from week to week. Following the inspection visits the manager confirmed that within the next year nine bedrooms, two lounges and the main entrance would be redecorated. Estimates were being sought to resolve the problem with the bath and to resurface the ramp. However, the registered person has not properly addressed the previous requirement to carry out a full environment audit and submit an action plan with timescales. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 20 Whilst the home has policies and procedures and some staff have received relevant training, infection control measures in the home are not properly put into practice. Four bedrooms have unpleasant odours of urine that need to be eliminated. There is no sluice facility; the laundry room was messy, with clothing on the floor and an overflowing bin without lid. Liquid soap and paper hand towels for hand washing were not provided in the laundry, bathroom and shower room. The requirement from the last inspection to assess infection control management has not been implemented. The manager has followed up on a pest control issue. Old Vicarage, The DS0000000374.V372627.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are appropriate staffing levels but recruitment is not fully robust, and training and supervision is not well organised to make sure all staff have the necessary skills to better support people. EVIDENCE: At the time of the inspection there was 18 residents, four of whom are older people with dementia. Staffing levels were four carers in the morning and afternoon and two carers in the evening and at night. The manager’s hours are in addition to these levels. The issue of only two carers on duty during the evening was discussed with management, as this is a potentially busy time when residents may need assistance to bathe and be helped into bed. The manager confirmed at the second visit that a revised rota was being started, with three carers in the afternoons and evenings. The majority of staff are employed on a part time basis. Existing staff provide cover for absences and agency staff are not used. There are sufficient weekly catering, domestic, and laundry hours. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 22 All seniors and carers have either achieved, or are studying for National Vocational Qualifications (NVQ) in care. The home therefore exceeds the standard for at least 50 of carers to have NVQ qualifications or equivalent. A sample of recruitment files was examined, for staff employed in the past year. Photograph and proof of identification is kept on file. Application forms are completed, with details of employment history. References appeared to be obtained from the person’s last employer, but it was sometimes difficult to ascertain the status of the referee. Professional/employment references should be sought as opposed to character references. Records of interviews are made. A declaration statement that the employee is physically and mentally fit to do the work has not been introduced. Staff are employed subject to Criminal Records Bureau (CRB) checks. However in one instance the person had started work without a preliminary check (POVA First) or CRB being carried out. Staff who spoke with the inspector demonstrated caring attitudes and a keenness to improve skills through further training. New staff undertake induction training to Common Induction Standards. There was no plan in place to give an overview of the training completed or planned for the staff team. The only evidence of training was certificates that are held on the employee’s file, and some certificates in a central file. This made it difficult to establish exactly what training the staff team has undertaken and what is needed or requires updating. Following the inspection visit the manager submitted a training plan for the next six months. Courses are being arranged on safe handling of medicines, protection of vulnerable adults, mental capacity act, infection control, dementia awareness, equality and diversity, care planning, food hygiene, diabetes, and further NVQ training. Old Vicarage, The DS0000000374.V372627.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Management systems are not sufficiently developed to support delivery of a service run in the best interests of people living at the home and promote health and safety. EVIDENCE: In the period since the last inspection the Registered Manager had left the home. A new manager, Mrs Joan Fidler was appointed in January 2008. She has many years of experience and has achieved care and management qualifications. Mrs Fidler is applying to the Commission for Social Care Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 24 Inspection to become the Registered Manager. A deputy and team of senior carers support the manager in her role. The home’s owner, Dr Dewan visits the home regularly. However reports on the conduct of the service by the provider have not been carried out on a monthly basis, as required, and these need to recommence. At the last inspection a requirement was made to introduce an effective quality assurance system. This had not been addressed. Following the inspection visits the manager devised a plan that sets out the range of methods that will be used to monitor and improve the quality of the service. This includes surveys with residents and staff, various audits, staff training and supervision, and planned improvements to the building. Residents spoken with during the inspection, and those who completed surveys, indicated they were generally satisfied with the service. Some relatives commented on what they feel the home does well. One person said, “I think they try their best to look after the clients and the care plans are kept up to date regularly”. Another relative described how staff cope well with her mother’s behaviour and said, “There’s always a family feeling amongst staff and residents”. Comments about how the service could improve included more activities, better quality food, and more staff at times. Resident personal finance records were examined. Individual account sheets are appropriately recorded and entries showed evidence of personal spending. Receipts are obtained for purchases and two staff, and the resident, where possible, sign each transaction. At the last inspection the home was required to improve individual supervision to ensure staff have supervision six times a year and that records are maintained. The manager and deputy take responsibility for providing supervision sessions and a recording format is available. A sample of staff files was checked and none had received regular supervision. Following the inspection visits the manager confirmed that a schedule of forward planned supervision dates has been drawn up. The home has a health and safety policy and range of associated procedures. Risks assessments for safe working practices (fire safety, moving and handling, first aid, food hygiene and infection control) have not been conducted. Staff require update training on safe working practices. Fire safety records showed regular fire instructions being given to staff, however these did not ensure the required frequency of six monthly for day staff and three monthly for night staff. This has since been rectified and dates for instruction are being forward planned. Checks and tests of fire alarms, emergency lighting and fire fighting equipment were being carried out at the correct intervals. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 25 Accident reporting is generally well documented, including checking people for injuries and any treatment or follow up action. However management need to ensure that all incidents are reported and recorded, for example a staff member who sustained a minor injury during an incident with a resident. Old Vicarage, The DS0000000374.V372627.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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 X X X 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? 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 OP19 Regulation 23(2)(b) (d) Requirement A full environment audit must be carried out and action plan submitted to CSCI with timescales for completion. (Requirement outstanding from inspection of 19.9.07) This must include action to rectify the building issues from this inspection concerning bathing and sluicing facilities, heating, ventilation and door guards. Essential steps to control infection in the home must be implemented. All areas of the home must be kept satisfactorily clean. (Requirement outstanding from inspection of 19.9.07) This must include action to rectify hygiene issues from this inspection concerning cleaning of commodes, provision of hand washing facilities and elimination of odours. Recruitment of staff must include: (a) A preliminary POVA First check or Criminal Records Bureau check DS0000000374.V372627.R01.S.doc Timescale for action 24/12/08 2. OP26 13(3) 24/12/08 3. OP29 19, Schedule 2 24/10/08 Old Vicarage, The Version 5.2 Page 28 4. OP33 26 5. OP38 13(4) being carried out before the person is employed (b) A declaration that the person is physically and mentally fit to do the work (c) Wherever possible, employer or professional references as opposed to character references (d) Clarification as to the status of referees. The Registered Person, or their representative must visit the home at least monthly and prepare reports on the conduct of the service. (a) Risk assessments must be carried out for safe working practices (b) All staff must be provided with up to date training on safe working practices 24/10/08 24/12/08 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 OP7 Good Practice Recommendations Care plans should be further developed to achieve a consistently good standard and demonstrate specifically the care/support each person requires to meet their needs. A photograph of each resident should be provided on his/her medication records for identification purposes. Regular social activities, outings and entertainment should be provided according to a planned programme to ensure people have opportunities for stimulation and contact with the community. Training should be organised according to the identified DS0000000374.V372627.R01.S.doc Version 5.2 Page 29 2. 3. OP9 OP12 4. OP30 Old Vicarage, The 4 5. OP36 OP38 training needs of staff and relevant to the needs of the people they support. Individual staff supervision should be carried out according to the home’s schedule, and provided at least six times a year. All accidents and incidents should be reported and recorded. Old Vicarage, The DS0000000374.V372627.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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