Inspection on 07/04/06 for Old Vicarage, (The)

This inspection was carried out on 7th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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) 18/07/07

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 Key Unannounced Inspection 7th April 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 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.V288749.R02.S.doc Version 5.1 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 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.V288749.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19 December 2005 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 24 bedrooms on two floors, 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. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a four hour period. During the inspection a tour of the building was undertaken. Some of the homes records were examined. Three residents files were seen and these residents were spoken with in detail. Other residents were also spoken with during the course of the inspection. Two staff were spoken with at length. The acting manager and deputy were not on duty at the time of inspection, the senior care staff that was in charge of the shift at the time of inspection therefore assisted the inspector. What the service does well: What has improved since the last inspection? Major improvements were noted since the last inspection with regard to the documentation and procedures that are now in place for the health and personal care and safety of residents. The recruitment practices of the home are now in line with the requirements and ensures that residents are supported and protected. The training requirements of the staff team have been reviewed and training within the home is now ongoing to ensure that staff are able to meet the residents personal and health, safety and protection requirements. The practices in the home are now robust with regard to the administration of resident’s medicines; again this demonstrates that resident’s safety is maintained. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 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) DS0000052437.V288749.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home ensures that prospective residents have the information they need to make an informed choice about where to live and a thorough assessment ensures that residents moving into the home will have their needs met . EVIDENCE: The statement of purpose was examined at the homes last inspection and a requirement left as it required further detail and explanation as to how activities and services were provided and the level of involvement and choices that were available to people living at the home. (This was left as a requirement at the previous inspection also) The statement of purpose and service user guide could not be located by the nurse in charge on the day of inspection, as both the acting manager and deputy were not on duty at the time of inspection. Of the residents spoken with some did have some awareness of these documents but stated that they had no particular interest in reading them, but confirmed that their relatives had read them. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 9 The acting manager was contacted by telephone and has agreed to send copies of the statement of purpose and service user guide to the commission for social care inspection, where they will be read by the inspector and any comments or suggestions fed back to the acting manager. The homes pre -admission assessment was not seen on the day of inspection however on discussion with the acting manager following the inspection it was confirmed that all the relevant information is contained within this assessment, this further demonstrates that no resident moves into the home without having their needs assessed and being assured that they will be met. The acting manager agreed to send a copy of the homes pre-admission assessment to the commission for social care inspection, where the inspector will read it and any comments or suggestions fed back to the acting manager. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 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 at least once during a 12 month period. 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 the service. The homes demonstrates that some of the residents health care needs are assessed, maintained and promoted, this however requires further development to ensure a robust practice is in place and maintained. Residents are able to make decisions about their lives and are given assistance as required whilst maintaining their privacy and dignity. EVIDENCE: Since the last inspection improvements were noted within the residents files seen, careplans and risk assessments are detailed . However the timescales given at the last visit had not been reached on the day of this insection and therefore some work has yet to be completed. Of the three files examined all had nutritional assessments in place but only one had a weight chart which demonstrated that the resident was weighed regularly to ensure their nutritional health was monitored and managed as required. When weight charts are in place within all residents files this will demonstrate that residents nutritional health needs can be monitored and met. Of the files seen one had in place a personal handling assessment which demonstrated that staff have the information required to allow them to safely manage this residents moving Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 11 and handling requirements in accordance with their needs. This needs to be demonstrated within all residents files, including residents that are independently mobile to ensure that staff have the information required to safely assist residents as required and ensure independence is maintained for residents who do not require assistance. Although the majority of careplans stated that the resident had been involved in the formulation of the careplans, no residents signatures were seen to evidence this, once this is in place it will further demonstrate that residents have not only been involved in the formulation of their careplan but are also in agreement with their careplan. Although care plans seen were found to be detailed in content they were not signed by the member of staff completing them and many did not have the review date documented, once this is in place it will demonstrate that staff take joint ownership with the individual resident for the formulation of the care plan and will ensure that the careplan is reviewed as stated and a continuity of care is maintained. Of the three residents files examined, who were all self funding there was no evidence to demonstrate that annual reviews had taken place within the home,the nurse in charge on the day of inspection stated that self funding residents recieved annual reviews which were undertaken by the home. Once evidence is in place to demonstrate that reviews have taken place this will further demonstrate that residents needs and wishes are reviewed and any changes required are made. At the last visit there were concerns regarding the administration of medication at night.. This was due to only one member of night staff having undertaken administration of medication training. A requirement was left to ensure that sufficient staff undertook this training. This training has now been undertaken by further staff employed at the home, which ensures that there are sufficient staff both at night and throughout the day that are appropriately trained to administer medication to residents. The nurse in charge on the day of inspection confirmed that further staff have also been booked onto this training and are due to undertake this within the near future. Of the three residents files seen one residents self adminstered their medication, and evidence was in place to demonstrate that this residents competence had been appropriately assessed prior to them to self adminstering their medication. A disclaimer regarding the residents responsibilties in self adminstering was also in place and had been signed by the resident. Residents who self adminster their medication have lockable facilities within their private accomodation to store their medication, these facilties were seen on the day of inspection. This demonstrates that the home ensures the health and safety of residents so far as is practicable with regard to safe administration of medicines. Several residents were spoken with during the inspection and residents confirmed that staff treated them with respect when assisting them with their personal care needs and within day to day contact .It was noted through observation that there was a positive relationship between the residents and staff. All of the residents spoken with stated that they recieved visitors to the home and confirmed that visiting hours were open and confirmed that they Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 12 were able to see visitors within their own private accomodation or if preferred within the communal living areas of the home. Some of the residents spoken with confirmed that they had a private telephone within their rooms. The person in charge on the day of the inspection stated that residents had this option if they wished. A portable payphone was also available within the home for use by the residenrs if required. In the three residentrs files examined it was noted that the residents preferred name was documented, this ensure that staff are aware of the residents preferred form of address and use this accordingly. Within the files examined there was evidence of visits from the residents doctor. Several of the residents spoken with confirmed that they had regular visits from the chiropodist. One file seen had documented evidence to demonstrate that the tissue viability of the resident had been assessed and was reviewed regularly,this documentation was not seen within the other two residents files examined. Once this information is in place in all residents’ files it will further demonstrate that residents health care needs are maintained and promoted as required. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 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 at least once during a 12 month period. 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 the service. Residents maintain links with family and friends and are assisted to exercise choices within their daily lives, however further work is required to ensure that the residents lifestyle and preferences matches their expectations and satisfies their recreational interests and needs. EVIDENCE: Several residents were spoken with on the day of inspection; three residents were spoken with in detail. Of the residents spoken with all stated that they would like further activities within the home.All confirmed that there was not enough entertainment and activities to occupy their time. The person in charge on the day of inspection stated that outside entertainers came into the home each Wednesday and provided a slide show one week and music and motion on alternating weeks. The residents spoken with confirmed this but stated that these entertainers were presently on holiday and hadnt visited the home for a few weeks. On discussion with the residents it was noted that the homes activity coordinator was on long term leave, the person in charge on the day of Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 14 inspection confirmed that the activity co-ordinator was on maternity leave and stated that no replacement had been provided in her absence. It was also confirmed by three of the residents spoken with that trips out of the home would be welcomed, including visits to the local shops in Bakewell. Residents were spoken to regarding the meals provided at the home and all of the residents spoken with where happy with the meals provided and confirmed that alternative meals were made available if required. However alternative meal choices were not displayed on the meal board situated outside the dining area. During the inspection staff were observed discussing with residents their preferred choice of evening meal.Menus were examined and discussion with the catering staff confirmed that alternative meal choices were available if requested. Residents were observed to be interacting positively with each other on the day of inspection, which demonstrates that personal and social relationships are developed within the home amongst the residents. Residents were able to recieve visitors as they wished- see standards 7-11 for further information. Some of the residents private accomodation was seen on the day of inspection and found to be individualised in décor. Residents are able to bring their own personal possessions into the home, and this was confirmed by the residents spoken with, although no inventory of residents personal belongings was seen within the residents files examined. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are protected from abuse and appear confident that the home responds to their complaints promptly and effectively. EVIDENCE: The complaints procedure was seen and found to be satisfactory. Three complaints have been investigated since the last unannounced inspection. The commission for social care inspection has investigated two of these complaints and requirements were left to address the issues found. To date the requirements left have been met within the timescales given. One complaint was made to the home by a resident and was with regard to faulty equipment within their private accommodation- this was resolved by the home, which demonstrates the home takes complaints seriously and acts upon them promptly and effectively. Residents spoken with appeared confident that if they had a complaint this would be taken seriously and dealt with promptly. Residents spoken with confirmed that they knew how to make a complaint and whom they would complain to if they needed to do so. The person in charge on the day of inspection stated that the majority of staff employed at the home have now undertaken adult protection training and the remainder of staff are booked onto this training within the near future. Staff training files were not available on the day of inspection, however two staff were spoken to, one of these being employed within the last four weeks and both demonstrated a good understanding of adult protection and the procedure to follow should they have evidence or suspicion of abuse or neglect. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 16 Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents at the home live in comfortable,safe surroundings which are kept in good order and maintained to a high level of cleanliness and hygiene. EVIDENCE: A tour of the building was undertaken during the inspection and was found to be clean.tidy and accessible to residents. The home is attractive in appearance and well maintained with a garden area and grounds that are visually pleasing and accessible to residents. During discussion with the person in charge on the day of inspection it was noted that not all residents rooms had lockable cabinets, although all residents self administering their medication did have this facility.All residents must be given the option to have a lockable facility within their own private accomodation, should this facility not be required then it must be documented within the residents personal file. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 18 Following discussion with a resident who had purchased a motorised scooter for use outside of the home, it was apparent that no suitable storage facilities were available for the scooter. The scooter was therefore stored behind a sofa within the conservatory. The resident that he felt this was an inconvienence to other residents as they had to move off the sofa when he wished to use his scooter. He also said that he did not feel that he should go out in the rain as he did not wish to then bring a wet scooter back into the home and felt that a suitable outdoor storage area, such as a shed would be preferable. On further discussion with the manager it was agreed that a secure outdoor storage facility would eliminate the disturbance of other residents and provide an easily accessible method for this particular resident to access his scooter and also maintain further independence for the resident. Residents spoken with were complimentary regarding the cleanliness and appearance of the home and stated that the home was always clean and tidy. One of the popular communal areas within the home appeared to be the conservatory,where many residents sat. On discussions with residents it was confirmed that the conservatory was a popular area as it provided good views of the grounds. Following the last unannounced inspection a requirement was left regarding the laundry floor, which at the time did not meet infection control standards, this requirement has now been met and demonstrates that the infection control standards of the home continue to be met. The homes policy on infection control was not available on the day of inspection; a requirement was left at the last unannounced inspection with regard to developing this policy to ensure that staff have a clear direction to follow best practice. The acting manager has confirmed that this policy has been developed and is now in place within the home. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are in safe hands and are supported and protected by the homes recruitment and training practices, which ensures their needs are met by the numbers and skill mix of staff. EVIDENCE: During the inspection the staff rotas were seen and demonstrated that the staffing numbers and skill mix of staff where appropriate to meet the needs of the residents. Residents spoken with confirmed that the staff within the home were able to meet their needs and felt the numbers of staff were sufficient . Several residents were very complimentary regarding the care provided to them and stated that the staff worked very hard. The recruitement practices of the home were seen on a previous visit in February 2006 and were found to be satisfactory, however at that time staff had not recieved the General Social Care Council handbook, this book sets the code of conduct and practice that must be followed by care staff within the social care field. Several staff confirmed that they are now in receipt of this handbook, and the acting manager confirmed that all staff are now in receipt of this code of conduct. At the last unannounced inspection there was an insufficient number of staff who had achieved a National Vocational Qualification (NVQ)in Care at level 2 and a requirement was left that a minimum ratio of 50 of care staff must achieve an NVQ 2 in care in line with national targets. It was confirmed by staff Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 20 and the acting manager that twelve care staff are to commence NVQ 2 in care this year- six staff in April and six staff in September. At present two staff already have an NVQ in care qualification- one at level 2 and one at level 4. This demonstrates that the home strives to ensure that residents are in safe hands at all times through appropriate staff training and development. Discussions took place with a member of staff recently employed at the home and it was confirmed that this member of staff had recieved a satisfactory induction prior to commencing employment at the home , this included moving and handling training and Protection of vulnerable adults training. It was also confirmed that an induction to the home was also undertaken and that this member of staff has worked with a Senior Care staff during her induction period. This demonstrates that the home follows best practice and ensures that new staff are appropriately supervised throughout their induction period thereby protecting both residents and the newly appointed member of staff. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health, safety and welfare of the residents is protected and promoted however further development is required to demonstrate that the home is run in the best interests of the residents EVIDENCE: The acting manager was not on duty on the day of inspection, therefore she was contacted by telephone following the inspection and confirmed that she has eight years experience of managing a care home and previous to this had ten years experience as a qualified social worker. The Acting manager has not yet undertaken a Management qualification but intends to commence this within the near future.The Acting manager has not yet applied for Registration with the Commission for Social Care Inspection, this was discussed and agreed Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 22 that an application for Registration would be applied for following the Acting Managers twelve week probationary period at the home. The homes Quality Assurance systems were not avatilable to see on the day of inspection, discussions with the Acting Manager following the inspection confimed that the homes quality assurance systems had not changed since the previous inspection but stated that she intended to review the wording of the residents satisfaction questionnaires to allow residents to provide comments rather than yes/no answers.This demonstrates the homes comittment to ensure the home is run in the best interests of residents. The Acting Manager stated that the proprietor visits the home regularly and is involved with decisions regarding the home. However the Acting Manager confirmed that the proprietor did not formally complete a Regulation 26 report,these reports should be undertaken on a monthly basis and form part of the quality assurance process, the content and type of visit was discussed with the Acting Manager. Discussions also took place with the manager regarding residents meetings, the manager confirmed that these did not take place at present , but confirmed that she would continue to develop systems within the home to ensure the residents views are heard and acted upon. Residents spoken with confirmed that residents meetings would be welcomed. Residents also confirmed that the proprietor visits the home and one residents spoken with stated that the proprietor had spoken with her, this resident said she would welcome more discussions with the proprietor. Residents moneys and transaction sheets were not available to examine on the day of inspection. Discussion with some residents confirmed that they were happy with the arrangements in place regarding their finances/monies. Staff spoken with confirmed that all the finacial transactions of residents was documented. However it was noted on discussion with staff that only the acting manager and her deputy had access to residents monies. Whilst this ensures a level of security and accountability is maintained it also restricts the residents access to their money if the acting manager or deputy are off duty, as they were on the day of inspection, and appears to assume that money required will be planned for in advance.However consideration must be given regarding residents who at the last minute choose to access funds from their account. The acting manager also stated that at present only one signature is provided on residents financial transactions. As a matter of good practice it is recommended that two signatures are provided on each transaction, preferably the resident and the member of staff retreiving or depositing the money or two staff if the resident is unable to sign. A requirement that was left following a visit to the home in January 2006 was that all accidents and incidents must be recorded in an accident /incident book. The home now has in place accident /incident forms and adult prorection report froms, which demonstrates that safe working practices are in place for both residents,staff and visitors to the home. Staff at the home have their own copies of the homes policies and procedures, however on the day of inspection the policies and procedures kept at the home Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 23 where not available to examine as the nurse in charge was unable to access or locate them. This practice needs to be reviewed as staff must have access to the homes practices, policies and procedures when on duty for reference if required. The home has a planned maintenance and upkeep programme this was seen and found to be satisfactory. Staff at the home had undertaken training in moving and handling and were able to answer questions confidently with regard to the use of techniques within the home in relation to this. Assessments were in place regarding the vulnerability of residents and the practice of these assessments were observed on the day of inspection, this demonstrates that residents health, safety and welfare are promoted and protected. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 X X 2 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 X X 3 Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 2 OP33 3 OP37 Regulation Requirement 15, Care plans and risk assessments Schedule must be generated from a 3 (1) (b) comprehensive assessment, and sets out in detail the action that needs to be taken to ensure that all aspects of residents’ health, personal and social care needs are met. Previous timescale has not yet expired 30/04/06 24 A system must be established that reviews the quality of care provided at the home and makes improvements as required, this should be done in consultation with residents. 26 Visits by the registered provider should take place once a month, be unannounced and include: interviews with residents and their representatives (with their consent) and interviews with persons working at the care home- to form an opinion of the standard of care provided, inspect the premises, its records of events and complaints and prepare a written report and supply a copy of the report to the commission for social care inspection and to the manager of the home. DS0000052437.V288749.R02.S.doc Timescale for action 30/04/06 31/07/06 01/05/06 Old Vicarage, (The) Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP3 OP12 OP22 OP24 OP33 OP35 Good Practice Recommendations Annual reviews of residents plan of care for self funding residents should be undertaken by the home and copies of these reviews kept within the resident’s files. Residents should be consulted about their social interests and arrangements made to enable them to engage in local, social and community activities A suitable storage area should be provided for residents equipment A lockable facility should be provided in resident’s private accommodation unless the reason for not doing so is explained in the care plan Consultation with residents and their representatives should be sought through regular residents meetings and residents satisfaction surveys Resident’s financial transaction records should be signed by the resident and the member of staff on each transaction. Where the resident is unable to sign then two staff signatures should be provided at each transaction. Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Old Vicarage, (The) DS0000052437.V288749.R02.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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