Inspection on 11/07/07 for The Old Vicarage

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

The Old Vicarage 31/07/06

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Snydale Care Home

Whiteley House

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

CARE HOMES FOR OLDER PEOPLE The Old Vicarage Vicarage Gardens Featherstone Wakefield W Yorks WF7 6AH Lead Inspector Susan Vardaxi Key Unannounced Inspection 11 July 2007 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 The Old Vicarage DS0000067007.V333645.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. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Vicarage Gardens Featherstone Wakefield W Yorks WF7 6AH 01977 708368 01977 708083 theoldvicarage@f2s.com 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) Calsa Care Limited Mrs Jean Chilton Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (30), Physical disability over 65 years of age (30) The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2006 Brief Description of the Service: The Old Vicarage is a detached a four-storey building, situated in Featherstone near Pontefract. The home was refurbished to provide accommodation for 30 people over the age of 65 years who may have dementia and mental health needs, physical disabilities and requiring personal care needs. The building with a newer extension is set in its own large grounds and is in close proximity to local amenities including post office public house and shops. Public transport is easily accessible with bus stops located a short walk from the home. The residential accommodation is set on three levels with two lifts for access. Twenty-four of the thirty places provided are single accommodation only one of these has a toilet facility. The three-shared rooms have toilet facilities. Toilet and bathing facilities are located on all floors. The manager occupies the fourth floor of the building. The fees charged in July 2007 were £380. Hairdressing and chiropody are charged in addition to the fees. The provider makes people aware of the service and the Commission through the service user guide. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that occurred on the 11th July 2007 from 09:00 to 18:00 over nine hours. The visit included talking with people living at the home, relatives, staff, the providers and manager. Some records were inspected; a walk round the building occurred and lunch was taken. Information provided by the manager prior to the visit has been included in the report. Prior to the visit 10 survey cards were sent to people living at the home, nine were sent to relatives and two to GPs. At the time of the visit six had been received from people at the home and seven from relatives, which were generally positive. Three incidents have occurred at the home since the last visit, which have been investigated under Wakefield Metropolitan District Councils Multi Agency Safeguarding Procedures. The most recent incident was still being investigated at the time of this visit. The providers have cooperated fully throughout the investigations on each occasion. The inspector would like to thank the people at the home and all who participated with the overall inspection process for their co-operation. What the service does well: The home provides a well-maintained, clean environment for people to live in. Comments made by people spoken with, and comments received from people who completed the Commission’s survey forms, were generally positive about the home and staff. The manager and staff work to maintain a friendly atmosphere encouraging relative participation and involvement in aspects of the peoples’ lives at the home. People spoken with looked clean and comfortable and interaction with staff was seen to be good. Some comments received stated “ relative is happy here” “staff act on what they say” home is always fresh and clean” “staff are friendly and helpful” “they care for him 24 hours a day making sure he’s safe and looking after his every need” “keep residents clean”. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There has been a good improvement in the storage and recording of medications however some further development with recording practices in respect of medications prescribed to be given in variable doses are needed. This is to ensure medications are always administered accurately and accurate records kept. Review of action needs to be taken, when staff have handled items affected by body fluids, to ensure cross infection does not occur. Where the providers’ act as appointees, the bank account should be opened in the name of the person to whom the money belongs and some cash be available at the home for people to access if needed. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 7 Consideration should be given to replacing the current method of recording people’s daily events to ensure that detailed and accurate information is recorded to ensure effective communication between staff and enabling changes in need to be monitored. 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. The Old Vicarage DS0000067007.V333645.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 The Old Vicarage DS0000067007.V333645.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): 1,3,6 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The pre admission arrangements for assessing people’s needs are satisfactory. EVIDENCE: The details on the registration certificate seen had been included into the statement of purpose providing people with information about the care needs the service is registered to meet. One of the owner’s of the home and the manager stated that pre admission assessments are carried out, and there was evidence of this on the records seen. Surveys completed by people living at the home prior to the visit showed that they had received sufficient information about the home prior to admission. Intermediate care is not provided at the home. The Old Vicarage DS0000067007.V333645.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): 7,8,9,10 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Care plans seen were designed to meet peoples assessed needs and included risk assessments; however some did not always include the action needed by staff to ensure people’s needs would be met appropriately. People are generally satisfied with the care provided. There has been a general improvement in the recording and administering of medications. EVIDENCE: Comments made on the surveys received by the Commission prior to the visit in respect of peoples’ care included relative is happy here” “staff act on what they say” home is always fresh and clean” “staff are friendly and helpful” “they care for him 24 hours a day making sure he’s safe and looking after his every need” “keep residents clean”. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 11 Care plans seen were designed to meet peoples assessed needs and included appropriate risk assessments. Records showed that staff were working to these and peoples needs were generally being met. There was discussion with the registered persons about how care plans could be further developed to ensure that staff knew the action take to assist people to get the care they need, e.g. when incontinence has occurred, to prevent falls, to ensure correct diet and monitoring following a nutritional assessment. The providers have informed the Commission since the visit that a review of all care plans was being completed, and would include these matters. A new form has been developed to record the daily events; this is a tick box method, which does not allow for detail to be recorded in respect of events as they occur. It was not possible to track the events following a person reporting to staff that they had fallen due to this method of recording. People were found to be having their health care needs met and appropriate referrals to healthcare professional were seen in files looked at. These records included visits of GP and district nurses, continence adviser and other health professionals. Some medications, medication records and storage arrangements were checked. It was pleasing to find that a substantial improvement had been made in the storage of medications, the manager said all tablets are now put on the blister packs, which have helped to minimise the storage space required on the medication trolleys. The monthly medication cycle had recently commenced, an audit of previous months records was not possible as the manager said the records were with the pharmacist at the time of the visit, she said this is the homes procedure used when returning medication. However the balances of medications in stock and the records seen were found to be accurate. Whilst overall medication practices should ensure people receive the medicines they need there were some areas for development that were discussed with the registered persons which include: • The directions on some eye drops did not state the eye to be treated or the date when the eye drops were opened needed to ensure correct treatment is given and the drops are administered within of the recommended timescale. • A hand written entry for an antibiotic seen stated “give twice daily”, the pharmacy label recorded one tablet twice daily, these were checked and the medication given and records balanced indicating that despite the staff entry not being as clear as the pharmacists the medication had been given according to the pharmacy label. Hand written entries on medication records had not been be signed and countersigned by staff to double-check to ensure the directions are accurate. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 12 • The actual amount administered/stored was not recorded for some tablets prescribed to be administered in variable doses; this is necessary to provide an accurate audit trail. The issues relating to medication where improvements were needed were discussed fully with the manager who said she would take the necessary action in respect of them. The manager said some medication training had been provided; some staff spoken with confirmed this. The Commission has been informed wince the visit that staff have been retrained in respect of the above issues. Staff were observed respecting people’s privacy and having regard for their dignity when given assistance during the visit. The Old Vicarage DS0000067007.V333645.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 excellent. People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The provision of activities provides opportunities for people to pursue hobbies and interests and contact with their relatives and community is maintained. EVIDENCE: People spoken with said more activities are now provided. The owners said an activities person had been recruited. The owners said they had asked the people at the home and relatives for their views of activities and a record of a meeting held in May 2007 was seen, and choices had been integrated into daily activities. Photographs of a “baking session” were seen, and games such as dominos, arts and crafts had been recorded. There were photographs of a person gardening, the owners had invited relatives to Christmas lunch, and twenty people had attended. An eighteen-piece brass band concert had occurred. Photographs taken during an outing to a local shopping complex were also available. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 14 The owners said all people living at the home have their own email address and password so that they can keep in touch with relatives/friends who live abroad, evidence of this was seen at the visit and a person living at the home said they keep in touch with their relative who lives overseas. Photographs were on display in the entrance to the home showing how a “Polling Station” had been simulated in the home at the time of the last local election where people were able to cast their votes in person and in the privacy of the “polling booth” the votes were then forwarded on by post to the local authority. The comments made on survey forms completed by people living at the home were generally positive about activities. Information provided by the owners prior to the visit showed that advocacy arrangements are in place for five people and s provider is appointee for two people. During the visit an NVQ assessor was in the home and was working with the cook who had just completed a nutritional training course. The cook said this had been beneficial and was helping her with menu planning. People spoken with said the meals were good and no complaints were raised during the visit. The meal was sampled, the meat was tender, and the meal had been cooked and was presented to a very good standard. The owners have fitted a complete new range of units and tiled in the kitchen since the last visit. The Old Vicarage DS0000067007.V333645.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): 16,17,18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Safeguarding issues are referred appropriately and detailed complaint investigations are carried out to support protection of people. EVIDENCE: Some people spoken with said they would know how to make a complaint if needed. A relative said they had complained to the manager who had recorded the complaint and the issues was dealt with and had not reoccurred. The complaints records seen showed the complaint and action taken had been recorded. The issues of an anonymous complaint, made to the Commission since the last visit was passed to the provider and was investigated under the homes complaints procedures. Two people who had completed surveys stated they did not know how to make a complaint, although the complaints procedure is in the service user guide seen in people’s bedrooms and also displayed in the entrance to the home. This was discussed with the registered person, who said they would revisit this with people. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 16 The homes arrangements for people to vote at local and general elections have been fully addressed in standards 12 to 15. Three safeguarding issues have occurred at the home, one was in respect of an allegation against staff at the home this is still subject to safeguarding procedures. Two incidents were in respect of issues involving two people living at the home, and were appropriately referred by the home for investigation under Wakefield Metropolitan District Council’s Multi Disciplinary Safeguarding Procedures. The home has a Whistleblowing policy, was seen included in people’s induction programmes however the policy needs to be a separate document, which clearly sets out staff’s duty under the policy and how they would be protected should they need to “whistle blow”. Some staff spoken with said they knew about the policy however were not sure what it referred to. When this was explained to them they said they would report any incident of abuse if they witnessed it occurring in the home. The providers have informed the Commission since the visit that they are reviewing the Whistleblowing policy, which will be discussed with all staff. The Old Vicarage DS0000067007.V333645.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): 19,23,24,26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is clean, well maintained and provides a pleasant environment for people to live in. EVIDENCE: Behind the home the providers have cleared some of the overgrown areas and levelled some areas in the grounds to provide areas for people to walk in safely. The areas of the home visited were found to cleaned and decorated to a good standard, and work is underway to provide more rooms in the future. The providers have fitted a new emergency call system throughout the home; staff said that it works well. People seen in the bedrooms were able to access the emergency call easily from where they were sitting in the rooms. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 18 Visitors spoken with said their relative did not have a key to their bedroom; they raised this as they said their relative had been moved because of people who wander into their bedroom. This was discussed with the providers and manager at the time and the Commission has been informed that risk assessments to establish who should be allocated keys are currently being completed. New floor covering has been fitted in some bedrooms and a lounge. The manager said the covering was non-slip to ensure peoples safety. Some of the pictures on the walls throughout the home are part of the homes fixtures, the providers said people are given a choice of having their own pictures on the walls, some did and some preferred the ones already in place. Evidence of peoples own pictures were seen in their bedrooms with other personal items including family photographs. The lifts were taken to other floors and they provided a comfortable ride. The kitchen has been refurbished since the last visit; the area has been fitted with new cupboards and work surfaces and some tiling has been done. A new dishwasher has been provided and the cook said she was very pleased with the work done. New shelves have been fitted in the laundry room and “wheelie bins” have been provided for staff to put laundry in so they don’t have to lift heavy laundry baskets. The providers have purchased two new washing machines, they said there were also two stored to use should the ones in use break down A member of staff was observed disposing of body waste in the sluice room, she said commode pots were rinsed in a detergent and left for domestic staff to clean. The manager said this method of cleaning had been apprroved by the Health and Safety infection control officer who has confirmed this with the Commission since the visit. The member of staff was wearing protective gloves throughout the procedure however she did not remove them when leaving the room this was brought to the manager’s attention at the time who said she would remind staff to remove their gloves and wash and dry their hands before leaving the sluice room to reduce the risk of cross infection to people. The Old Vicarage DS0000067007.V333645.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): 27,28,29,30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staffing levels and training are adeuqate to ensure peoples needs are appropriately met.. EVIDENCE: On arriving at the home at 09:00 twenty-three people were up, dressed and some had had their breakfast. They looked clean and well groomed; some were in their dressing gowns waiting for staff to assist them. Times of rising and going to be were in care plans seen, no one spoken with said they had to get up unitl they wished to. In the morning, from 7.30am, there were three carers on duty, and the manager works from 8.30-5.00. Three carers work in the afternoons, although this is depleted to two carers when one is assigned to the kitchen for part of the evening shift. Two staff work at night from 10pm-7.30am. Comments on two surveys completed by relatives showed they felt more staff were needed however there was no indication that needes were not being met. Information provided by the manager prior to the visit showed that more than two people needed two staff to assist them day and night The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 20 It was observed on staff files and rosters seen that newly recruited night staff have been calculated in the staff hours one or two days after commencing their employment, and were not supernumerary allowing them to be supervised an experienced member of staff on an ongoing basis until they were assessed as competent. Staff records seen showed some people work at this home and other settings and there was discussion with the manager about the need to monitor the continiuous hours. The manager and staff spoken with said some staff have completed some training in Dementia care, medication, infection control, manual handling and first aid. NVQ care training is ongoing. Information provided by the manager prior to the visit showed that basic food hygiene, nutrition health and safety and fire training have also been provided. Some staff recruitment records were seen and two references, Criminal Records Bureau (CRB) and Protection of Vulnerable Adults from Abuse (POVA) checks had been obtained. One person’s employment could not be tracked prior to 2000; this was discussed with the provider who said they would check this with them and the Commission has ben informed since the visit that the required checks have been completed. The home’s Equal Opportunities policy was seen on some staff files, those recruited recently did not have a contract, the provider said he was waiting for the “proposed changes in legislation” before issuing them. One person’s records showed English was not their first language they had attended a literacy course in July 2007, the staff roster showed that she had worked under supervision for one night only. The owner and manager said the member of staff worked under thensupervision of an experienced member of staff as night staff always worked in pairs. This was discussed with the manager and the providers as due to situations that could occur in the night this may not always be possible who said manager would be avaiable within minutes if needed at night. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The providers’ work to ensure the home is managed effectively and that health and safety systems are in place to ensure people are safe. EVIDENCE: The manager has a management qualification, and over three years managerial experience, the providers, who assist with the business aspect of running the home, support her. A provider works on night duty on occasions and they said they do unannounced visits to the home and these reports would be available for inspection if needed. The home renewed the Investors in People Award in March 2007. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 22 Records of staff meetings were seen they showed that changes to the home are discussed and evidence of this was observed throughout the visit. The home sends questionnaires to relatives as part of the homes quality assurance programme, letters of thanks sent to the home from satisfied relatives were seen and very positive comments had been made, statements made include “ thank you for the “care and dedication given” “the home is improving all the time”. Some people’s financial records for personal allowances held by the home were checked. The current arrangements provide a detailed account of transactions made on their behalf and receipts for purchases had been obtained and could be tracked. However some people’s records showed them to be “overdrawn”. The provider said this was “only on paper” as their monies were banked and people always had access to the hairdresser, chiropodist etc who billed the provider who then paid the hairdresser etc. The provider has informed the Commission since the visit that this has been reviewed and all peoples balances have been brought up to nil or positive balances. A provider said he is appointee for two people and he had been unable to open bank accounts in their name; therefore bank accounts were in his name. Some mandatory training has been provided, and is referred to in standards 19-26. A system has been developed for sending all food deliveries to the home into the basement, which prevents staff manually lifting items, and carrying the items down the stairs. A wheelie bin has been provided so staff don’t have to lift the laundry baskets. Some records seen showed that system checks and equipment services had been completed. The running hot water temperatures on hand basins seen were recorded. The temperatures of running hot water on the baths had not been taken, and some of these tested at below 38 degrees centigrade. The provider said they would increase the temperatures slightly to deliver at no more than the recommended 43 degrees centigrade. The provider said he would also check the arrangements for testing hot and cold-water storage temperatures and tests for Legionnella with environmental health services. The Commission has been informed since the visit that this has occurred. The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X 3 3 X 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 24 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 OP26 Regulation 16(2)(j) Requirement Staff must follow infection control procedures, including the changing of rubber gloves after each incident of handling body fluids, to minimise the risk to people of cross infection The registered person must obtain written explanation from applicants when gaps in employment have occurred before people are employed at the home. Timescale for action 31/08/07 2. OP29 19 Schedule 2 31/08/07 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 OP7 Good Practice Recommendations The daily events tick box recording should be reviewed to ensure peoples individual issues are adequately recorded to evidence the care they receive and issues that arise. • The medication records should include which eye is DS0000067007.V333645.R01.S.doc Version 5.2 Page 25 2 OP9 The Old Vicarage to be treated to ensure the drops are administered as prescribed. • Eye drop dispensers and cartons should both be dated at time of opening to ensure they are not administered out of the recommended timescale. • Hand written entries on medication records should be signed and countersigned by staff to ensure the directions are accurate. • The actual amount of medication prescribed to be taken in variable doses (e.g.) analgesics should be recorded to ensure a clear audit trail is maintained. 3. OP16 The revised complaints procedure should be distributed to people at the home and their representatives to ensure people are aware of the action to take should they not be satisfied with the service. • The Whistleblowing policy should be revised and discussed with staff to ensure they understand their duty under the policy and be clear about the action to take to ensure people would be protected. • The registered person should ensure that advocacy arrangements are made to ensure the safe handling of service users monies particularly when they lack mental capacity and are unable to make informed choices. • Where providers are appointees for people living at the home, peoples’ bank accounts should be opened in the name of the person to whom the money belongs. • Where the registered person has agreed to hold money on behalf of people living at the home, people should be able to access cash from their personal account at all times. 4 OP18 5. OP35 The Old Vicarage DS0000067007.V333645.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 The Old Vicarage DS0000067007.V333645.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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