Inspection on 03/09/07 for Old Vicarage, The

This inspection was carried out on 3rd September 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 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 24/09/08

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

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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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Old Vicarage, The 2 Waterville Road North Shields Tyne & Wear NE29 6SL Lead Inspector Aileen Beatty Key Unannounced Inspection 09:30 19 September 2007 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.V344242.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.V344242.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 Dr Sandeep Dewan Mrs Doris Nicholson 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.V344242.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. 25th July 2006 Date of last inspection Brief Description of the Service: The Old Vicarage is a privately owned residential home situated in a residential area of North Shields, close to the town centre. The home provides personal care (no nursing care) for up to twenty-five elderly 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. Fees range from £363.77-£370. Information about the home is available including inspection reports. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit in February 2007 • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 19th September 2007 During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit (Delete if not applicable). We told the manager and provider what we found. What the service does well: The home promotes a person centred philosophy of care. This means that care is given in a very personal way that takes into careful consideration the wishes and feelings of residents. Relatives are very happy with the care provided and regularly write to the home to say so. Comments include, “My mother was surrounded by great love, care and laughter”. Another praised staff by saying “we applaud the extraordinary teamwork which made it possible for dad to spend his last few months in a caring environment”. Residents say they are happy with the care provided. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 6 A good range of training is provided to staff. This enables them to care for residents safely and to provide a high standard of care. Staff eat lunch with residents. This encourages staff and residents to be seen as equals and encourages communication. 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.V344242.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.V344242.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): 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are carried out before and after admission to ensure that people’s needs can be planned and properly met. Most information is available to help people make choices about the service before moving in. EVIDENCE: A service user guide and a statement of terms and conditions are available to all residents moving into the home. These documents contain most of the information required such as information about the homeowner, manager and staffing, the admission criteria and range of services available. There are some minor amendments to be made due to staffing changes and it was suggested that some information is missing. The information for residents and their families state that the home provides “personhood maintained care”. An explanation of what this is would be helpful. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 9 A pre admission assessment is carried out before admission. A form is completed by the home and these were available in records read. The assessment includes an assessment of physical needs and any special equipment or adaptations that may be required. Social information and personal details such as next of kin and important contact details are recorded. Mental health concerns such as memory loss, anxiety or depression are assessed and this information forms the basis of the initial decision as to whether the home can meet the needs of the prospective resident. Old Vicarage, The DS0000000374.V344242.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of care planning gives a good level of information to staff to support meeting residents needs. Care is planned sensitively with residents in a way that they prefer. However, some physical care plans lack detail. Satisfactory assessments are not always available which coule mean that some care needs are not fully met. EVIDENCE: All residents have care plans, which record their needs and describe how staff must meet these. The manager promotes a style of care planning that encourages staff to see residents as a whole person and not a set of tasks. This is good practice. This does mean that some care plans can be quite general and lack specific detail especially physical ones for problems such as diabetes. A number of physical needs are recorded as a separate care plan. The remainder of care plans read demonstrate a good knowledge of the individual and their needs and preferences. Instructions in care plans are Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 11 careful to ensure that any interventions by staff do not highlight weaknesses of the resident and that they give positive feedback for small achievements. For example, a resident may be able to dress themselves, but forget to put on an item of clothing or put it in the wrong order. The care plan will instruct staff to praise the achievement and some time later offer some assistance subtly so that they do not immediately draw attention to the error. This type of person centred care has been credited with helping to promote self-esteem and a sense of well being. An appointment system has been introduced for baths to ensure residents are helped to have a bath at a time to suit them by the worker of their choice. Special equipment is available such as hoists and bath aids. Some residents would be able to be transferred using a standing aid but there isn’t one available in the home, just full weight bearing hoists. This could take away some independence from some residents and the least invasive alternative should always be used first. It was confirmed that a standing aid and one hoist would be more useful that two hoists. Residents spoken to say they feel well cared for. Comment cards and letters of appreciation are available and state “my mother was surrounded by great love, care and laughter”. Another praised staff by saying “we applaud the extraordinary teamwork which made it possible for dad to spend his last few months in a caring environment”. Physical assessments are carried out by staff and reviewed on a regular basis. These include an assessment of social history and recreational needs in the form of a “This is your life” document. A seven day post admission assessment gives information relating to mood, personal care, mobility, continence, sleep patterns, and nutritional needs. This information helps to inform care plans. Some files checked were missing some of the assessment documentation, although staff and manager can recall it being gathered. The manager is investigating how this information has been removed from the file or possible filed incorrectly and will personally carry out audits to ensure they are complete in future. Reviews are held regularly by staff and relatives are always encouraged to attend although attendance by family members tends to be poor. There is evidence of the home trying hard to engage families in the care planning process by offering various appointments. Medication procedures in the home are good. The pharmacist has been changed from Boots to Lloyds pharmacy. Medicines are provided in a monitored dosage system and staff on duty responsible for the administration of medicines were able to describe the procedure for ordering, receipt and disposal of medicines well. The medicine trolley was clean and tidy and the temperature of the room and fridge are taken regularly and recorded. There are no controlled drugs in the home at present. Medication tracking records are available for inspection. The fridge contained eye drops not dated from the Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 12 date of opening. This would make it easier for staff to remember to discard them when they have been open for the required period. Remaining stocks of medicines are held appropriately. The privacy and dignity of residents are maintained in the home. Staff address residents in the way that they prefer, and although staff are very friendly and affectionate towards residents this is appropriate and professional. Residents are dressed in their own clothes at all times and are clean and tidy in appearance. Assistance is clearly given to help people maintain a satisfactory standard of dress and personal hygiene. A number of residents have their own room key and all residents are able to see visitors in private. There are no shared bedrooms and many rooms are en suite. Old Vicarage, The DS0000000374.V344242.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have adequate opportunities to take part in a variety of leisure pursuits and interests, which help them maintain links with the local community and keep and develop social skills. Mealtimes are flexible to suit individual preferences and lifestyles. Residents are given plenty of choice and sensitively supported to eat meals where they have specific needs. EVIDENCE: Resident’s interests are recorded in a “This is your life” document. This records past history and previous interests and hobbies and helps staff to plan appropriate activities. One file checked did not contain this document or social assessment and it was suggested that it may be due to the problem mentioned previously of incorrect filing and this will be addressed by the new auditing system. The manager described a number of activities that take place in the home. It was reported that many residents are reluctant to take part in some activities Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 14 that they would not have taken part in when living at home, and there are some problems engaging some residents. Evenings are a more popular time for activities and some spontaneous activities also take place such as dominoes. Some residents go out into the community to be involved in activities. Staff facilitate this by arranging taxis and escorts, and liaising with other agencies. The managers self assessment recognises that there is room to improve the amount of activities available and how these link with assessed needs and social care plans. One suggestion is that residents could be more involved in daily domestic household tasks if they wish. Residents are able to receive visitors in private at any reasonable time of the day. There were no visitors present during the inspection. Care plans are written in a way that maximises resident’s ability to exercise personal autonomy and choice. Residents are able to choose what they wear, what time to get up and what and when to eat. Residents were observed being offered choices in all of these areas during the inspection. Bedrooms are nicely personalised and homely in appearance. The inspector joined residents at lunchtime. Staff always sit and eat with residents at lunch time which gives them the opportunity to offer discreet help and encourages open communication between staff and residents. Residents enjoyed the meal on the day of the inspection although it was not what was advertised on the table menu. The cook explained that some new choices were being tried at lunchtime to see if they would make a successful supper. Table menus list meals for the week and also drinks that are available. Tables are nicely set and the meal was sociable and residents enjoyed the meal. One resident gathered all the plates on the table and enjoyed this responsibility. The weekend cook has left and meals are now cooked at the weekend by senior care staff who hold a food hygiene certificate. These meals are prepared in advance by the regular cooks and both cooks said they are happy with the standard of meals provided. Residents also confirmed that they enjoyed the meals although one resident described them as okay while acknowledging that cooking for a large number is not the same as being at home. Fresh fruit is made available daily although this is not always eaten. Kitchen staff puree some of this fruit and pour over ice cream as a sauce to encourage residents to eat it. Kitchen staff demonstrated a good awareness of special diets and supplemented meals. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are satisfactory complaints and protection procedures which would protect service users from risk of harm. EVIDENCE: There were no complaints recorded since the last inspection. The manager said that only very minor “niggles” had been expressed by visitors and residents and these had been immediately resolved. It was suggested that such concerns, however minor, should be recorded to assist the manager with quality monitoring. A complaints procedure is displayed throughout the home including communal passage areas and bedrooms. There has been one adult protection concern since the last inspection. The manager and owner of the home managed this satisfactorily and took appropriate action when the issue came to light. The manager in particular worked closely with social services and safeguarding adults services to address the concern. An action plan is in place to ensure that all staff are adequately trained and aware of what to do in the event of an adult protection concern arising. This includes training (which most staff have already attended) and a reminder of related policies and procedures such as whistle blowing will be carried out during staff supervision sessions. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 16 A new missing persons form has been devised to help the process run smoothly should a resident happen to leave the building without supervision. It is a checklist of what staff must do and who to contact. It would be useful to have a form that could be given to the police with the persons details and a description of what they were last seen wearing and any other distinguishing features. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is satisfactorily maintained and refurbishment has made it a more pleasant setting for residents, although an ongoing programme of redecoration has not yet been completed. The home is satisfactorily clean and is in the process of implementing the recommendations of the health protection agency. EVIDENCE: The home is generally clean and well maintained. The inspection involved a tour of the premises including most communal areas such as corridors, lounges and bathrooms. Not all bedrooms were inspected but a sample from each floor was. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 18 Communal lounges are nicely decorated and are homely in appearance. On the second day of the inspection some furniture was being moved out of the smoking lounge including the television, to comply with new smoking legislation. The TV has now been moved to the non-smoking lounge as it has a wide screen, replacing the old one in there. The main entrance is clean and odour free, and contains a signing in book and information for visitors. The two toilets next to the ground floor lounge are in need of redecoration and upgrading. The ceilings are cracked and paintwork is flaking. Windows also need to be repainted. The walls above the tiles in one bathroom need to be repainted. The windows have been painted on the inside to provide some privacy but this is messy and unsightly. The seal behind the sink needs to be removed and replaced. High ceiling cobwebs are noticeable in a number of rooms in the home and should be included in a list of regular tasks to ensure they are removed on a regular basis. The dining area is pleasant and clean and tidy. The floor is a washable and non-slip. A new microwave and dishwasher have been provided in the kitchen and staff there feel they are well equipped to carry out their work. Some work has been identified by the Environmental Health Officer including that the kitchen needs to be repainted, as there is flaking paint on the ceiling above a food preparation surface and some tiles need to be replaced. The fly screen is damaged as staff have torn it in order to be able to open the window. The manager confirmed she is aware of the environmental health report and that plans are in place to address these issues. Most bedrooms are nicely personalised and homely. Many residents have brought in their own furniture and personal belongings. There is some malodour in a small number of rooms and the manager stated that carpets are being replaced as part of a rolling programme. A full environment audit would be beneficial as a number of areas requiring attention were observed these included general maintenance such as damaged toilet seats and damaged sealants in some en suite rooms and marked walls. The window in one bedroom was found to have some rotting in the wooden frame. This was pointed out to the manager. This had caused one of the screws holding in a window restricting chain to come off, although a secondary restrictor remained secure. Some en suite bathrooms face onto Waterville Road. Although the glass is patterned, two residents spoken to said that they felt exposed when standing in the bathroom with the light on for example as an outline would still be visible. The manager agreed that blinds can be provided to improve privacy and is more than happy to do so. Shelving is required in some en suite bathrooms for toiletries. A number of bedrooms have no name on the door, especially upstairs. This would help residents and unfamiliar staff find bedrooms more easily. One toilet was full of washing drying on airers. All bathrooms should be available for use by residents. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 19 Externally there is a nice, well maintained garden area. During the inspection it was noticed that a fence had been placed across a lawned area to provide better security. This was not properly secured and paving stones were broken during the fitting of the fence. The manager reported following the inspection that this has now been removed and the paving stones will be replaced. The wooden handrail on the ramp is rotten and hazardous. The ramp has been patched numerous times and would benefit from resurfacing. Tiles are loose in bathroom 3 around the bath and some grout is missing and dirty. The home is generally clean and hygienic. The manager has attended training with the health protection agency and is planning to implement the “essential steps” outlined by them. This includes better documentation of general and major cleaning, timescales to be included for quality monitoring purposes and so that no important cleaning tasks get missed. All bedrooms are going to be fitted with hand towel and soap dispensers and bins with foot operated lids. Staff were observed placing dirty sheets on the floor during the last inspection. New linen skips have been provided and this no longer happens. Following the infection control training, the laundry now uses oxygen cleaning agents for foul laundry that cannot be washed over forty degrees. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are in post to meet the diverse needs of residents. Robust recruitment procedures are in place which help to prevent risk of harm to residents. EVIDENCE: There are sufficient staff employed in the home. Agency staff are not used, but a bank of familiar staff are available to cover absence. Many staff in the home have worked there for a long time and there are no problems with retention of staff. One of the deputy managers has left the home. Following this and discussions regarding the management of the home during safeguarding meetings, a full review of staffing and management arrangements has been carried out. There will be one manager and two deputy managers covering the home, in addition to care staff and senior care staff. The manager will be on duty predominantly Monday to Friday but with some weekend and evening shifts to monitor the home fully. In the afternoon between 1p.m and 5p.m the manager will be able to carry out office work, attend meetings and reviews and organise training. There will be deputy cover each day up until 10.pm. The proprietor will meet with the manager formally each Friday to discuss the running of the home. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 21 Nine staff in the home have NVQ level two, three have started level 3, one has level 4 and three have been enrolled and are waiting to start. New staff are enrolled on training promptly and receive an induction and mandatory safety training in appropriate timescales. Staff files were read and those seen contained all of the required recruitment information such as criminal records checks and two references. The manager is a qualified tutor (City and Guilds 7407 adult tutor) and therefore delivers a number of training courses in house. Most of the courses delivered by the manager have been purchased as training packages including first aid and food hygiene. The manager also delivers manual handling training and staff complete work books from South Tyneside College. It was suggested that the manager seeks external advice about how to ensure she remains up to date with changes in practice (such as first aid) and whether the agencies providing the training packages provide such updates. This is particularly important in practical areas where practices may change. Lists were made available of the training provided and training planned. This includes, in addition to the above, equality and diversity training, accredited dementia awareness training, fire safety, and safeguarding adults. Some certificates are available although some staff have taken them home and a number need to be filed. Training records would be more easily accessed if they were held in a more systematic way and the manager is looking at how this can be achieved. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has an open style and is clearly present in the home to give direction and support to staff. She has done much to change the culture within the home to ensure that the service is led by the needs and wishes of residents. Quality assurance systems are in place but need to be further developed. This will help the service to shape the quality of the service and ensure it is run in their best interests. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 23 EVIDENCE: Doris Nicholson is an experienced manager who describes a clear passion for her work and making sure residents are happy, safe and enjoy the best possible quality of life. She is supported by two deputy managers. One deputy has recently left and will be replaced. A review of management arrangements has taken place which allows Doris more time to concentrate on quality assurance and record keeping. Although the care provided in the home is very good, records do not always reflect this and the approach to quality assurance can tend to be reactive and corrective as opposed to preventative. That said, Doris has put systems in place, but where things have fallen down this has been due to her having insufficient time to check procedures are always being followed by senior staff members. This is a crucial aspect of effective management and the new arrangements will now afford Doris the time and support required. The influence Doris has had on the attitudes of staff and the standard of person centred care is very evident in the home. Although staff were previously very caring, they now demonstrate an even greater insight into how they approach residents and how this might affect their emotional well- being. This is particularly true for residents with dementia. A check of residents funds found that they are stored securely in separate envelopes and accurate balances were found during a random sample. Receipts are kept and a record is kept of all incoming and outgoing payments. Staff supervision is carried out but this is not sufficiently organised to ensure that it takes place six times a year. Records are held of some discussions with staff but more structured supervision notes need to be maintained. The manager has already identified that supervision systems need to be improved. It is suggested that while it is appropriate for the proprietor to supervise Doris, it may be useful for her to also have an identified “buddy” or mentor from another home who is more up to date with practice issues. The home is generally very safe. Systems are in place for the regular checking of equipment and facilities. Staff receive training in safety related topics such as safe moving and handling, first aid, food hygiene (including safer food better business) fire safety and infection control. Accident and injury records were checked. These had been completed fully with ample detail. At times there was no evidence that a regulation 37 form had been sent to the Commission for Social Care Inspection which is required to notify of a serious accident or injury. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 24 A new zero tolerance policy has been implemented to make clear to visiting members of the public that staff will not tolerate aggressive or offensive behaviour. A poster is displayed in the main entrance but not in the residents area in case this distresses them. Most areas of the home are safe. Some hazards were identified during the inspection. The wooden handrail on the ramp is rotten, and the ramp would benefit from resurfacing, as it is patchy. The window in an identified room has a rotten frame and there may be others affected throughout the home. A new fire assessment has been carried out in May 2007 and electrical appliances were checked in April 2007. Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 25 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 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation Schedule 1 Requirement Update statement of purpose and service user guide to reflect changes and to include range of needs catered for by the home, and that nursing is not provided. All service users must have a copy of the pre admission assessment in their file. Care plans must all be evaluated on a regular basis to ensure all residents’ needs are being met. OUTSTANDING since February 2007 Physical care plans must be provided for specific ailments and be sufficiently detailed to meet physical needs. Physical, social assessments and weights must be kept up to date. OUTSTANDING Since February 2007 A standing aid must be provided to aid residents while maintaining maximum independence More opportunities for social DS0000000374.V344242.R01.S.doc Timescale for action 19/11/07 2. 3. OP3 OP7 14 (1) 15 19/11/07 19/10/07 4. OP8 15 (2) (b) 19/10/07 5. OP12 16 (2) 19/11/07 Page 27 Old Vicarage, The Version 5.2 (m) 6. OP19 23 (2) (b) (d) activities must be available to provide adequate stimulation and variety. 1. A full environment audit must be carried out and action plan submitted to CSCI with timescales for completion. 2. Blinds must be provided in en suite bathrooms to ensure privacy. 3. Storage must be provided in en suite bathrooms to enable toiletries to be stored conveniently and hygienically. 19/11/07 7. OP26 4. All bathrooms must be accessible to residents. 13 (20 (3) Confirm essential steps recommended b the health protection agency have been implemented to ensure service users are protected. Ensure all areas of the home are kept satisfactorily clean. Effective quality assurance systems must be in place to ensure that there is an ongoing improvement plan so that practice issues and developmental needs can be identified and addressed. All staff must receive supervision at least six times a year and a record maintained. Repair rotting window frame and rotten wooden handrail on ramp. 19/12/07 8. OP33 24 (1) 19/12/07 9. 10. OP36 OP38 18 (2) 13 (40 (a) 19/11/07 19/11/07 Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Old Vicarage, The DS0000000374.V344242.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Old Vicarage, The DS0000000374.V344242.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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