Inspection on 12/02/09 for St Vincent House

This inspection was carried out on 12th February 2009.

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

St Vincent House 12/03/07

St Vincent House 04/01/06

St Vincent House 15/07/05

St Vincent House 14/03/05

St Vincent House 22/11/04

St Vincent House 22/03/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE St Vincent House 20 - 21 Clarence Parade Southsea Hampshire PO5 3NU Lead Inspector Annie Kentfield Unannounced Inspection 12th February 2009 11:30 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 St Vincent House DS0000012388.V374072.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. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Vincent House Address 20 - 21 Clarence Parade Southsea Hampshire PO5 3NU 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) 023 9242 2822 murat@stuch.1wanadoo.co.uk St Vincent Care Homes Ltd Manager post vacant Care Home 27 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) 2. Physical disability (PD). The maximum number of service users to be accommodated is 27. Date of last inspection 12th March 2007 Brief Description of the Service: St Vincent House is one of four care homes for older people, owned by St Vincent Care Homes Limited. The home is a large and well-maintained period property in a popular location. There are fine views at the front across the Southsea Esplanade and the Solent. There is plenty of communal space including three lounges, a dining room and a secluded courtyard garden at the rear. The accommodation is arranged over four floors with 21 single bedrooms and some shared rooms, all with en-suite facilities. There is a wide staircase and a passenger lift that provide access to the upper floors. Outside there is a ramp for wheelchair access to the front of the home. There are no parking facilities at the home but there is plenty of onstreet parking nearby. The local council makes a charge for this at certain times of the day. The range of fees for this home is between £415 and £650 per week, depending on the room occupied and the level of care provided. Inclusive in the weekly fee is access to reflexology and exercise classes. There are additional charges for chiropody, hairdressing, newspaper, transport and the cost of staff escorts. The additional fees are detailed in the service user guide. St Vincent House DS0000012388.V374072.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 two stars. This means that people using the service experience Good outcomes. We made an unannounced visit to the home on 12 February 2009 with one inspector (Annie Kentfield) and the visit lasted for 7 hours. During the visit we spoke to the responsible individual, the manager and some of the care staff. We spoke to four residents in the privacy of their own rooms and met two visitors to the home. We looked at some of the home’s records including care plans, medication records, staff training and recruitment records and some of the health and safety records. Before the visit we received the Annual Quality Assurance Assessment (AQAA). This is a self-assessment that provides information about what the service does well and where further improvements are planned. The home has not had a registered manager for the last twelve months. The deputy manager has taken on the role of manager in this period with overall responsibility taken by the previous registered manager who is now the responsible individual. The responsible individual is the group manager for St Vincent Care Homes Limited. However, the manager has not made an application to the commission for registration, and this is a legal requirement. What the service does well: What has improved since the last inspection? St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has completed an extensive programme of building and refurbishment. This has created a new dining room, kitchen, laundry and staff area and created more communal space on the ground floor for the residents, as well as one additional bedroom. All of the bedrooms now have en suite facilities. 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. St Vincent House DS0000012388.V374072.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 St Vincent House DS0000012388.V374072.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): 3 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do not move into the home unless their care needs have been assessed and the home is confident they can meet those care needs. The home does not provide intermediate care. EVIDENCE: The home has a pre-admission assessment process that is carried out by the manager. The home gathers as much information about new residents as possible including information from families and health and social care professionals involved in a persons care. Prospective residents are encouraged to visit the home and stay for a meal, and to stay for a trial period of 4 weeks before making the decision to move into the home. Some of the residents had been unable to visit beforehand and received help in choosing the home from St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 9 family or friends who visited on their behalf. We spoke to two residents who told us that they already knew the home before they moved in. When we looked at some of the records of assessment the manager told us that the home completes enough of the assessment to inform staff about a plan of care, and then a more detailed care plan is completed when residents have been in the home for four weeks and staff have more information and know the residents better. St Vincent House DS0000012388.V374072.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 good. This judgement has been made using available evidence including a visit to this service. The health care needs of the residents are met with regard for privacy and dignity. Medication is safely stored and dispensed. Risks to residents’ health, safety and well-being are assessed and action taken to minimise any risks, however, the risks are not always being recorded and reviewed. EVIDENCE: The home currently uses a cardex system to record the care needs and care plan for each resident. The care plans record what staff need to do to meet the individual care needs of each resident and include health care needs, dietary assessments, weight checks and contact with GP’s, District Nurses or other specialist health care services. Care staff record the care that is given on a daily basis. The care plans include detailed information where it has been identified that residents require monitored fluid or food or have special dietary needs. Weight checks are recorded monthly. The responsible individual told us that the home is planning to introduce a new care planning system that is more person centred and comprehensive. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 11 The care plans record any risks to residents safety or well being that have been identified in their care plan, such as the risk of falling or the risk of developing pressure areas. However, two residents who go out of the home independently did not have a risk assessment or management plan recorded as to how any risks or events would be managed. The manager told us that they had considered the risks of people going out but strongly support residents’ rights to go out when they want to, and staff monitor this. However, this had not been recorded in the care plans. We also noted that one person had bed rails on their bed but there was not a risk assessment recorded to manage this risk and the use of bed rails as a form of restraint. In discussion we found that a new hospital type bed had been purchased by the home for this resident. The bed had integral safety rails that some of the staff had been using. When this was investigated it was confirmed that the resident was not actually at risk from falling out of bed and the bed rails did not need to be used. Some of the residents had requested portable electric heaters in their bedrooms during the exceptionally cold weather. These had been provided, however, we found that some of the heaters were extremely hot to touch and may have presented a risk to frail or dependent residents if they tripped or fell. Immediately following the inspection, the responsible individual confirmed in writing that the home had reviewed all of their risk assessments and risk management plans to ensure that all risks to residents are recorded, with an action plan for care staff that will be regularly reviewed and updated. The AQAA states that the home employs a trained reflexologist and chartered physiotherapist to provide an additional service to residents when appropriate. When we spoke to residents they told us that staff in the home are kind and caring and always respond when they use the alarm call system to ask for help. Residents confirmed that privacy is respected and staff always seek permission before entering bathrooms or bedrooms. We noted that shared bedrooms have screens to promote privacy. During our visit one of the residents in the sitting room needed some urgent assistance from care staff and screens were provided to give the resident privacy and respect dignity. We noted that when residents were being moved in wheelchairs, staff always used the footplates for the comfort and dignity of the residents. The manager takes responsibility for the management of medication that is prescribed for the residents. A local pharmacist regularly inspects the medication administration systems in the home and the last inspection of October 2008 did not report any concerns with the systems in the home. The St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 12 pharmacist looks at medication storage, recording procedures and reviews medication to ensure that the home is not over stocking on regularly prescribed medication. The manager told us that she regularly requests a review of residents’ medication from the prescribing GP’s and that the home are able to contact GP’s if they have an concerns about individual medication. The home has a policy and procedure on the safe administration of medication, for care staff, and staff have access to current information about medications in the home. Medication is securely stored and the medication fridge is regularly checked to ensure that medication is stored at the correct temperature. There were some gaps in the medication administration records and we discussed this with the manager. We were told that senior staff would be checking the medication administration records more frequently to ensure that staff sign the record when medication is given. Gaps in the records mean that residents may not have received their medication as prescribed. However, staff also record medication given, on the blister pack and this had been checked and recorded to show that medication had been dispensed. However, medication that is prescribed to be given as and when needed may not be in a blister pack. We observed medication being given and staff were aware of the need to check that medicine had been taken or not before the record was signed. The regulations for the safe storage of controlled drugs have been amended and the responsible individual confirmed that the home’s storage for controlled drugs meets current regulatory requirements. St Vincent House DS0000012388.V374072.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 good. This judgement has been made using available evidence including a visit to this service. The home offers residents opportunities for social and leisure activities of their choice. Residents are offered a choice of meals and snacks throughout the day. EVIDENCE: The home employs an activities co-ordinator and an arts and crafts teacher. Residents told us that there are music and movement sessions, manicures and a hairdresser and occasional entertainers or musicians. Some of the residents like to take part in the organised activities and one resident showed us their work from the arts and crafts class. Another resident told us that they preferred to go out each day or would like someone to go with them. Another resident told us that they preferred their own company and liked to watch television in their room. There are outings arranged in the warmer months and the home has the use of transport that is shared with another home. All activities that take place are recorded with details of how many people participate. Residents have access to books, games and videos or DVD’s if they choose and the use of the mobile library. One resident told us that they would like more opportunities for trips out of the home. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 14 The AQAA told us that the home has installed a digital TV system in the home. There are plans to further improve daily life and social activities for the residents by providing more one to one activities for those residents who do not want to, or are unable to take part in group activities. The home employs a cook and there is a seasonal 4-week menu with a number of choices for breakfast, lunch, tea and supper. Comments about the food varied, some of the residents thought it was very good and others thought the food is good “sometimes”. Residents have hot and cold drinks throughout the day and the dining room has a water fountain and soft drinks fridge for the residents. The dining room is spacious and well furnished and is an attractive place for residents to take their meals. Some of the residents prefer to have their meals in their rooms, or in one of the sitting rooms. The statement of purpose for the home, and the annual quality assurance assessment states that residents would be supported to take part in religious worship of their choice if any residents identified this as a choice. St Vincent House DS0000012388.V374072.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 good. This judgement has been made using available evidence including a visit to this service. Residents are protected from the risk of harm or abuse. The home has an open approach to comments, complaints or feedback about the service. EVIDENCE: The home has a formal complaints policy, that is accessible, to deal with any complaints. None have been received and the Commission has not received any complaints about the home since the last inspection. The home welcomes comments and suggestions for improvements by having a suggestions box in the entrance. The annual quality assurance assessment told us that as a result of listening to the views of the residents and visitors - a number of changes had been made: A new entry system to the home has been installed, and Christmas shopping trips were arranged for the residents, and the home arranged for an in-house shopping facility during the Christmas period. The responsible individual told us that staff are aware of their responsibilities to report any concerns about the safety and protection of residents and safeguarding awareness training is provided for staff. The home has a policy and procedure on safeguarding vulnerable adults for staff to access. We have not received any safeguarding concerns about residents in the home since the last inspection. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 16 The responsible individual told us that the home will be providing training for staff on the new Mental Capacity Act and will be reviewing their policy on the deprivation of liberty. The responsible individual confirmed that the home has a copy of the Code of Practice for the Mental Capacity Act. St Vincent House DS0000012388.V374072.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, 23 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a safe, homely and comfortable environment to live in. The home is clean and hygienic. EVIDENCE: Since the last inspection the home has completed an extensive programme of building work to create a new kitchen and dining room, new bedroom and ensuite facilities, new laundry, office, and staff room. This has also created additional sitting room space for the residents. We noted that the home is furnished and decorated in an attractive and domestic way with pictures, ornaments, flowers, books and plants to make the building ‘homely’ for the residents. Residents can personalise their bedrooms as they wish and the statement of purpose says that residents are encouraged to bring personal possessions and items of furniture when they move in. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 18 The home has installed a new coded entry system that makes the building secure for the residents. Residents are able to access a sheltered and safe courtyard area, with seating available in the warmer months. We spoke to four residents in their own rooms. Residents expressed satisfaction with their bedroom and told us that they have everything they need. Two residents were in shared rooms, they told us that they had chosen to do this. Shared rooms were equipped with screens for privacy. One resident told us that the en-suite bathroom did not have any heating and they found it very cold, and the water temperature in the wash hand basin was very cool. These concerns were discussed with the responsible individual who confirmed in a letter following the inspection that the maintenance team will be installing a heater in the bathroom. The problems with the water temperature had already been noted and action was being taken to remedy this. The report has already highlighted the use of portable electric heaters in some bedrooms. Following the inspection visit, the responsible individual confirmed in writing that risk assessments were now in place for the use of portable heaters. The home employs cleaning staff and all parts of the home that we looked at were clean and pleasant. The annual quality assurance assessment confirmed that the home has policies and procedures for good practice in infection control. Shared bathrooms and toilets have hand-washing facilities of liquid soap and paper towels, as good practice. Staff have access to gloves and aprons. The home has a laundry and employs someone for four hours each day – Monday – Friday, to undertake laundry work. The home told us that they have improved the laundry system to overcome problems that occurred in the past with residents losing personal items or receiving the wrong items. All personal clothing is marked and it is the responsibility of key workers to ensure that residents have the right items of clothing returned to their room. However, one resident told us that they sometimes find that other people’s clothes have been placed in their room. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care and support needs of the residents are met by a staff team who are trained and competent to do their job. However, records of staff training were not up to date and easily accessible. The home does not have a registered manager. EVIDENCE: We looked at the staff rota, which shows that there are four care staff on duty between 8am – 2pm and three care staff on duty from 2pm – 8pm, with two care staff on waking night duty. In addition, the manager works from 8am – 4pm, Monday – Friday, and the home employs an administrator, activities coordinator, and six catering and domestic staff. When we spoke to some of the residents they told us that staff are always available when they need help. Two of the residents said that they would like staff to have more time to take them out. The responsible individual told us that the home uses agency staff to cover any shortfalls in the staffing rota. The home always uses the same agency and the responsible individual confirmed that checks are carried out on agency staff. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 20 The annual quality assurance assessment tells us that 10 of the 14 care staff have achieved a National Vocational Qualification (NVQ) in care, at level 2 or above. The responsible individual told us that there is a staff training programme that covers all of the mandatory areas of safe working practice. The staff training matrix was not available when we visited and this was sent to us following the inspection, however, the training matrix did not indicate what training had already been completed, only training that was planned for this year. The home is changing the way that training is delivered and have invested in a new training programme that will deliver accredited training to the managers of each care home in the group, who will then become accredited trainers, to cascade the training to care staff. We saw a sample of the new training programme, which covers first aid, food hygiene, health and safety, fire safety, risk assessment, diet and nutrition, dementia care, manual handling, infection control, coping with aggression, safeguarding, bereavement, equality and diversity, legislation and mental capacity act. As the training programme is not yet fully implemented, the outcomes have not been assessed and reviewed by the responsible individual. The manager had recently completed the moving and handling and first aid sections of the new training programme. We spoke to one member of staff who confirmed that they receive regular training opportunities and that their training in safe moving and handling was up to date. The staff member also told us that they receive formal supervision every couple of months. The manager told us that she carries out spot checks and monitoring of practice in the home, sometimes at weekends or in the evenings, and keeps a record of these as part of staff supervision. New staff follow an induction programme that follows nationally agreed standards for staff working in care. The home has a key worker system and each key worker reports to a shift leader or assistant manager. We looked at the recruitment records for two new members of staff. The records show that new staff do not start working in the home until satisfactory written references and checks have been received. However, one of the records did not contain a full employment history with dates of starting and leaving, and the other record did not contain evidence of the POVA (Protection of Vulnerable Adults) first check, however, the POVA first check had been recorded as being received before the person started to work in the home. One of the records did not contain a copy of proof of identity. The responsible individual confirmed that new staff are supervised until a satisfactory criminal record check is received. The home has not had a registered manager since January 2008. Responsibility for running the home in the interim period has been taken by St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 21 the deputy manager under the supervision of the responsible individual. However, the home is legally required to have a manager who is registered with the commission, to take responsibility for the day-to-day management of the home. St Vincent House DS0000012388.V374072.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 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents and the service is responsive to the views of the people living in the home. However, the home does not have a manager who is registered with the commission. The health and safety of the residents and staff is promoted and protected by systems to ensure that the requirements of relevant health and safety legislation are always met. EVIDENCE: The home does not have a registered manager. However, the deputy manager is skilled and experienced and has worked in the home for a number of years. The responsible individual is in the home on some days each week to take St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 23 overall responsibility for the management of the home until the manager is registered with the commission. The registration process for managers is a legal requirement to ensure that managers are suitably skilled and competent to manage the care home and protect the safety, health and well being of people using the service. Residents’ financial interests are protected. The policy of the home is that residents manage their own money, or they have support from an independent advocate or representative. Small amounts of personal monies are looked after and these are recorded and regularly audited. The home employs a health and safety consultancy to carry out regular health and safety risk assessments and provide specialist advice. We looked at some of the health and safety records for fire safety. These were up to date and there is a notice in the home advising residents and visitors that the fire alarm is tested weekly. The home had a recent food safety inspection and we were advised that there were no requirements. The annual quality assurance assessment (AQAA) was completed and returned when we asked for it. The AQAA provides evidence that the service is regularly reviewing the quality of care provided and is committed to continually improving outcomes for people using the service. The AQAA states a commitment to promoting equality and diversity in practice, through plans to develop person centred care planning and promoting “freedom of expression in all aspects of the day to day running of the home”. The AQAA says that the service holds regular residents’ meetings, to which family and friends are also invited, and sends out questionnaires to residents and visitors. The AQAA does not tell us how the service provides a summary of the outcomes of the annual quality assurance process to residents and visitors. St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 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 2 X 3 X 3 X X 3 St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 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 Regulation 13(4) Requirement The registered person must ensure that all parts of the home to which service users have access are free from hazards to their safety. Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Identified risks to service users must be recorded and reviewed with clear guidance for care staff on how risks or events are to be managed. Timescale for action 30/03/09 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 St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 St Vincent House DS0000012388.V374072.R01.S.doc Version 5.2 Page 27 - 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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