Inspection on 14/06/07 for St Vincent`s Care Home

This inspection was carried out on 14th June 2007.

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`s Care Home 07/11/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE St Vincent`s Care Home Down Road Bexhill-on-sea East Sussex TN39 4HD Lead Inspector Chris Woolf Key Unannounced Inspection 14th June 2007 09:05 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`s Care Home DS0000066775.V341936.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`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Vincent`s Care Home Address Down Road Bexhill-on-sea East Sussex TN39 4HD 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) 01424 211244 01424 213739 St Vincent’s Care Ltd. Ms Gillian Gilkes Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That service users are aged sixty five years (65) and over on admission The maximum number of service users to be accommodated is twenty five (25) 7th November 2006 Date of last inspection Brief Description of the Service: St Vincent’s is a large, detached Edwardian property, standing in its own grounds next to the parish church of St Stephen’s in a quiet residential area of Little Common. It is within ten to fifteen minutes walking distance from Bexhill town centre. The home is registered to provide residential care for twenty-five older people. Accommodation comprises nineteen single bedrooms and three bedrooms that can be shared at service users request. All but three of the service users bedrooms have en-suite toilet facilities. Assisted communal bathing and showering facilities are provided in the home. There is a lounge, a lounge/dining area, and an attractive garden for service users use. A passenger lift provides level access to the upper floors of the home. And a chair lift is fitted to the short flight of stairs, leading to some of the service users bedrooms on the lower ground floor. The current fees for the service at the time of the visit range from £370 to £600 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. There is currently no e-mail address for the home. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this report has been gained from questionnaires received from 6 service users, 1 relative, and 1 health care professional; and from an unannounced visit to the home lasting 7 hours. The visit included a tour of the premises. Talking with the manager, and her deputy, the majority of service users, 5 visitors, and 4 staff. Observation of the interaction between service users and staff; an activities session taking place; a meal being served; and medication being administered. And inspection of a variety of records kept by the service. What the service does well: The home has a friendly and welcoming atmosphere. A member of staff said, “There is a good atmosphere, it’s a lovely place to work”. The home is clean, bright and well maintained throughout. A service user commented, “Cleanliness is one of the high spots” Service users receive excellent food. One service user commented, “she is a xxxx good cook, I would give her 5* any time”, and a member of staff said, “The food is wonderful, you cant fault it, they get a good choice of options”. The staff in the home are friendly and efficient. Service users said, “The staff treat you in a friendly way, they are sweet and kind”, and “the staff are very good”. A staff member commented, “It is the happiest place I have ever been. The staff are brilliant”. Service user comment cards included, ‘This home is run to a very high standard’, and ‘St. Vincent Care Home is home from home with good food and staff’. Visitors commented, “Its excellent here”, and “You will have no problems whatsoever with them here, they are very good” St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 7 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`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, & 4. Standard 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be assured that their needs will be assessed and that the home will be confident of meeting these needs prior to their admission. EVIDENCE: There was a requirement on the last report that information about the home including previous inspection reports should be fully accessible in the home. These documents are now on display in the entrance hallway for all to see. The statement of purpose is currently being revised to reflect the fact that if a service user develops dementia after admission to the home, they can St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 10 continue to live there for as long as the home are able to meet their needs. Service user comment cards confirmed that they had received sufficient information about the home before moving in and that they had received a contract. One comment card stated ‘My son visited some home’s and decided that this home was right for me’. A visitor commented, “My solicitor and a retired nurse both recommended the home”. The manager, or her deputy, visits all prospective service users prior to their admission to the home to undertake a comprehensive pre-admission assessment. For those service users who have a care manager a joint assessment is also obtained. The home has demonstrated that it is able to meet the needs of their current service users. 2 service users have developed dementia since admission. These two service users continue to be accepted by the other service users as part of the home’s ‘family’, and staff have received training in dementia to ensure that they can continue to meet the service users needs. A further service user, whose dementia needs had started to cause disruption in the home, is no longer a resident. This home does not offer the facility of intermediate care. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health and personal care needs are recorded in a plan of care and are met by the home, supported by a multi-disciplinary health care team EVIDENCE: An individual plan of care is produced for each service user, based initially on information received during the pre-assessment process. These care plans are holistic and include details of the service users history, physical and mental abilities and needs, dietary requirements and weight chart, health & hygiene, social spiritual and occupational needs, and medication. Care plans are reviewed informally with the service user on a monthly basis and all changes St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 12 are documented. Following discussion at the site visit, the home is now intending to ensure that service users have the opportunity to sign the monthly reviews to confirm their agreement. The home has also indicated that they will amend their daily reports to ensure that they comply with Data Protection and to include more detailed information. The health and personal care needs of service users are met by the home, supported by doctors, district nurses, chiropodist, optician, dentist, RNIB, and other professionals as required. All visits to or from health professionals are recorded in the care plan. The home operates a key worker system and one staff member commented, “I am key worker for 5-6 residents”. Service user and visitor comment cards confirmed that they receive the care and support they need, and that they receive the medical support they need. One commented, ‘When I need the support they are there’. A service user said, “They look after me pretty well”. Visitors’ said, “They really are kind and look after her”, and “Her chiropodist visited and told me he thought that she seemed so content”. Staff have recently received training from the district nurses on administration of Insulin, and are now undertaking this task on a regular basis. The home uses the Nomad system for their medication. The systems for the receipt, administration, and disposal of medication are sufficient to allow an audit trail to be undertaken. Fridge items are stored in the kitchen refrigerator and the home was waiting for the delivery of a new locked box to be used in the fridge for the storage of these medications. All staff that administer medication have received training in this subject. There were a few minor concerns regarding medication, a no longer used and out of date medication had not been returned to the pharmacy but this was addressed on the day of the site visit; one bottle of eye drops had not been dated on opening; there was no sign on the door where Oxygen was in use, but the manager said she would make a temporary sign until one could be obtained; and some written instructions on a medication administration record sheet had not been double signed and dated. A requirement has been made to address these areas. Staff at the home treat service users with respect and uphold their right to privacy and dignity. Service users said “The staff do treat you with dignity”, and “The staff always knock on my door”. Visitors’ commented, “Xxx is happy, he is always clean and immaculate, and they always have nice clean beds”, and “They keep the residents nice and clean”. Staff confirmed that they always knock on doors, keep service users covered up, keep doors closed when doing personal care, and always ask the service user what they want done for them. St Vincent`s Care Home DS0000066775.V341936.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, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to maintain a full and interesting lifestyle, and to keep in contact with their friends and family. They have choices in all aspects of their lives and receive a wholesome, nutritious and varied diet. EVIDENCE: Since the last inspection the frequency and range of activities on offer to service users have been developed. They are also taking place more regularly. On the morning of the site visit an exercise session was taking place. This was led by one service user and a further 10 service users took part. Service users commented, “I enjoyed the exercises, they should have them more often”, “I can feel my limbs zizzing afterwards”, and “I don’t like exercises”. Regular St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 14 weekly activities include Games, Quizzes, Exercises, and Bingo. A service user commented, “Some of the ladies do a bit of gardening”. A Staff member said, “They like reminiscence”. Visiting entertainers are also brought in to the home and have included, a clothing sale, physical motivation, and ‘land army girls’, Service users commented, “We had ‘Lavender Storm’ here yesterday - they were very good, all the old songs”, and “We do get some good entertainers”. A visitor said, “They get entertainment and games”. The home intends develop its system for recording activities to include a record of the individual attendance at each of the activity sessions. Comment cards from service users included the statements, ‘There are activities but I don’t like to take part’, ‘Physical exercise (well supported); quizzes (well supported); bingo (some people cant join in because of poor sight); tea in the garden; and cream tea out of doors in the summer,’ and ‘We have quite a few outside entertainers come in which I enjoy, we have keep fit and some weeks a quiz, but most of the residents will not join in so it is very difficult’. A hairdresser visits the home regularly for those who wish to avail themselves of this service. Service users religious needs are supported by the home. Currently there are 2 churches providing regular religious services to those who wish to participate, and visitors from the church also take some of the service users out. Staff also take service users to the local church from time to time. A visitor commented, “A visitor from the church takes her out, they took her to see her own hairdresser”. A service user comment card stated, ‘We have two services here, one Methodist one Church of England every fortnight which is good’. Currently there are no service users with diverse ethnic or cultural needs. Service users visitors are made welcome in the home and commented, “The staff make me welcome”, “I visit every day”, and “The staff make me very welcome, they are very pleasant”. Visitors are invariably offered a cup of tea and often also offered lunch, especially if they have travelled some way to see their relative or friend. Service users said, “We get taken out by our close friends”, and “Most of us here have visitors”. A staff member commented, “A visitor often stays for lunch on a Sunday”. There are choices for service users in all aspects of their lives. A staff member commented, “Some residents don’t want to do activities, it’s their choice”, and a service user said, “We go to bed when we like”. Everyone spoken to agreed that the meals provided in the home are excellent. Service users commented, “The best part is the cook, the food is brilliant”, and “The cook always makes a cake for birthdays”. Visitors said, “Xxx thinks the food is good”, “The food is very good, quite a variety, they ask if there is anything else they would like for a change”, and “Xxx has come on in leaps and bounds since being here, her appetite has increased”. A staff member said, “The food is brilliant she is such a good cook”. Positive comments about the food were also received on service user comment cards. These included, St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 15 ‘The cook who is here has been in her job at this home for a long time and she dishes up some great meals’, ‘The meals are tip-top’, and ‘The cook is particularly good at asking if there is anything we would like for lunch or supper that we have not recently had or that we would like for a change’. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ concerns and complaints are listened to and acted upon and they are protected from abuse EVIDENCE: The home has a clear complaints procedure and a copy is on display in the hallway. Since the last inspection there have been three complaints recorded, all three were satisfactorily resolved and outcomes were recorded. The way in which the home records complaints does not comply with Data Protection and the manager is making arrangements to remedy this. Service user and visitor comment cards confirmed that they know who to speak to if they are not happy or if they wish to make a complaint. One included the comment, ‘I’ve never yet had the occasion to use this knowledge’. A service user said, “We have no complaints”, and visitors commented, “I have no problems at all”, and St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 17 “I have heard no adverse comments at all”. A service user comment card included the statement, ‘I am very contented here’. The home has robust Adult Protection and Whistleblowing policies and procedures to ensure that service users are protected from abuse. No new member of staff is employed until a satisfactory check has been made against the Production of Vulnerable Adults register. All staff attend adult protection training. Staff indicated that they were aware of the Abuse Policy and would know what to do if they suspected abuse, or potential abuse. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is clean, comfortable and well maintained. EVIDENCE: The home is well maintained inside and out, with pleasant and accessible gardens. All radiators in the home have been appropriately covered for protection against burns. Since the last inspection maintenance has continued with some new décor and furnishings; a new boiler has been installed and there is new equipment in the laundry; self closing door guards have been St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 19 fitted on some doors; externally new guttering and a new fence have been erected, and improvements have been made to the communal garden. There is a maintenance plan for the home but this is at present kept by the owner and a recommendation has been made that a copy be retained in the home. Service users benefit from having a separate lounge and a lounge/dining room, giving them a variety of places to sit and either talk to other service users or their visitors, or to just enjoy their own company. Furnishings and fittings throughout are comfortable and homely. All but three of the bedrooms are fitted with en-suite toilet facilities and there are sufficient other toilet and bathrooms available to meet service users needs. Since the last inspection a new shower room has been provided giving service users the choice of whether they wish to bathe or have a shower. Although currently this shower room is seldom used, it is a very good facility. Assisted bathing is available where required. There is a shaft lift to provide access from the ground to the first floor and a stair lift to give access to the rooms on the lower ground floor. The home is currently researching which company can provide them with the most suitable hoist as they require one that can fold down sufficiently to be transferred using the lift. The call bell system used by the home is very outdated, consisting of door bell type call points with only one room with a longer accessible bell, and a panel where the call can be cancelled without the member of staff entering the service users room to find out why they have called. A requirement is made that a new call system is provided with an accessible alarm facility in every room. All bedrooms are comfortable and have been personalised to meet the service users needs. Currently most of the double rooms are being used for single occupancy, when they are used as a shared room screening is available to ensure privacy for personal hygiene tasks to be carried out. Service users commented, “I’ve got all my photo’s in my room”, and “I’ve got some of my own furniture”. The home is kept very clean with no unpleasant odours and service user comment cards confirmed that the home is always clean and fresh. At the time of the site visit the home did not use special sacks for soiled linen, but these are now being ordered. Infection control procedures include the use of gloves and aprons, separate pad bins, yellow bags, and liquid soap and hand towels. Service users commented, “Its always clean”, and “My room is always clean, its wonderful”. Visitors said, “Its clean, no unpleasant odours”, “No odour”, “Always clean”, and “The bedding is always clean”. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 20 St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A sufficient number of properly recruited and adequately trained staff meet the needs of the service users EVIDENCE: Sufficient staff are on duty at the home to meet the needs of the service users. Service user comment cards confirmed that there are staff available when needed and stated, ‘Yes, I need them very little but they are always available’ and ‘We just need to remember that staff need a day off and a study day, but there is always someone to take the place of the one off duty’. A staff member said she felt there was sufficient staff on duty to meet the needs of the service users apart from at times of last minute sickness. Currently four members of care staff have attained NVQ to level 2 or above and 3 have almost completed this training. When these 3 qualify in September the level will be 50 . A further 4 staff have already enrolled for St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 22 the training and when they qualify it will bring the level to 78.5 . Staff commented, “I have just started doing NVQ”, and “I have almost finished my NVQ”. Recruitment processes are good. No new member of staff is employed until 2 satisfactory references have been received, an enhanced disclosure has been submitted to the Criminal Records Bureau, and a satisfactory check against the Protection of Vulnerable Adults register has been received. However the home do not at present ask for a full employment history on application forms and the files do not comply with the revised Schedule 2 of the regulations therefore a recommendation is made to cover this. All new staff have induction training to ‘Skills for Care’ specifications. A member of staff said, “I am doing my Induction”. Staff have received most of the mandatory training apart from infection control which is next on the training plan. A recommendation is made regarding this. The cook confirmed that she is waiting for a date to do her Intermediate Food Hygiene certificate. Staff have also done a 5 week course in Dementia care. Staff who administer medication have received training and have also received training from the district nurses in the administration of insulin. Comments about the staff from service users included, “The staff are very nice”, “The staff are very good”, and “They are a marvellous lot here”. Visitors said, “The staff vary”, and “They are very good”. General comments from staff included, “I am very happy, they have all made me welcome”, “We work as a team”, “It’s a lovely home, I love it here”, and “I am only leaving because I am moving away, it’s a lovely place to work”. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 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 service users; and the health, safety and welfare of service users and staff are protected EVIDENCE: The manager has been the Registered Manager for the home for 9 years under both the previous and current ownership. She holds a City & Guilds advanced management for care certificate. A Deputy Manager and a dedicated team of St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 24 staff support her in her role. Staff confirmed that they get support from the manager and the owners and commented, “We get support from the manager and deputy”, “We get 100 support from the manager”, “We definitely get support from the manager, she is good as a friend as well as a manager”, and “I like the new owners very much, they are doing lots of improvements, if we need anything we get it”. A visitor said, “The deputy manager is very good, very caring”. The home has a variety of quality assurance strategies in place and is further developing these. Questionnaires are circulated to service users or their representatives. Residents Reviews are held regularly. The residents have a committee meeting every four months. A service user said, “We have committee meetings”. Another service user made the suggestion that the home should have a ‘post box’ this was discussed with the manager who agreed to arrange for this to happen. Staff meetings are held 6 monthly. The manager and deputy join in the verbal handover of shifts. The owner now carries out regular, unannounced, documented reviews. A system of regular audits is being developed. The home only holds small amounts of petty cash for service users, and the process and procedures for dealing with these are sound. The health, safety, and welfare of service users and staff are protected. Risk assessments are in place and regularly reviewed. Safety checks seen are up to date and relevant. Accident reports are in order. First aid notices have been revised. St Vincent`s Care Home DS0000066775.V341936.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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 26 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement All medication that is no longer used must be returned to the pharmacy, all eye drops and liquid medication should be dated on opening, hand written instructions on MAR sheets should be double signed and dated, and any room containing Oxygen must have appropriate signing. A new call system must be provided with an accessible alarm facility in every room, and which cannot be cancelled other than at the point of call Timescale for action 31/08/07 2. OP22 23 (2) (c) & (n) 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations A copy of the maintenance plan for the home should be retained in the home DS0000066775.V341936.R01.S.doc Version 5.2 Page 27 St Vincent`s Care Home 2 3. OP29 OP30 Recruitment files should be updated to comply with the Revised Schedule 2 of the regulations, particularly with regard to requesting a full employment history All staff should receive Infection control training, as planned. St Vincent`s Care Home DS0000066775.V341936.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local 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. 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